Publications

Abstract

Objective: Antibiotic use at the end of life (EoL) may introduce physiological as well as psychological stress and be incongruent with patients’ goals of care. Advance care planning (ACP) related to antibiotic use at the EoL helps improve goal-concordant care. Many nursing home (NH) residents are seriously ill. Therefore, we aimed to examine whether state and regional ACP initiatives play a role in the presence of “do not administer antibiotics” orders for NH residents at the EoL. Methods: We surveyed a random, representative national sample of 810 U.S. NHs (weighted n = 13,983). The NH survey included items on “do not administer antibiotics” orders in place and participation in infection prevention collaboratives. The survey was linked to state Physician Orders for Life-Sustaining Treatment (POLST) adoption status and resident, facility, and county characteristics data. We conducted multivariable regression models with state fixed effects, stratified by state POLST designation. Results: NHs in mature POLST states reported higher rates of “do not administer antibiotics” orders compared to developing POLST states (10.1% vs. 4.6%, respectively, p = 0.004). In mature POLST states, participation in regional collaboratives and smaller NH facilities (<100 beds) were associated with having “do not administer antibiotics” orders for seriously ill residents (β = 0.11, p = 0.006 and β = 0.12, p = 0.003, respectively). Discussion: NHs in states with mature POLST adoption that participated in infection control collaboratives were more likely to have “do not administer antibiotics” orders. State ACP initiatives combined with regional antibiotic stewardship initiatives may improve inappropriate antibiotic use at the EoL for NH residents.

Abstract

In 2019, 10 to 20 million school-aged youth were identified as having a chronic health condition or disability. However, little is known about U.S. school district policies on school nurses’ participation in Individualized Educational Program (IEP) and Section 504 teams to support these youth. Using nationally representative district-level data from the 2016 School Health Policies and Practices Study, we examined whether U.S. school districts have policies on school nurse participation in IEP and 504 development. In addition, we examined the relationship between having such policies and policies on (a) creating and maintaining school teams to assist students with disabilities and (b) the participation of other essential school staff in IEP and 504 development. Among districts with policies regarding school nurse participation in IEP development versus those that did not, a significantly greater proportion had policies on student support teams and counselors’ participation on IEP teams (79.2% vs. 44.4%, p <.001, and 98.7% vs. 56.2%, p <.001, respectively). In addition, among districts with policies on school nurse participation in 504 development versus those that did not, a significantly greater proportion also had policies on support teams and counselors’ participation on 504 teams (77.5% vs. 43.1%, p <.001, and 97.2% vs. 50.7%, p <.001, respectively). We also examine regional and locale differences in these policies. Findings encourage discussion on student support teams’ role in school districts for students with chronic health conditions and disabilities, how school nurses can be essential team members, and better coordination of student care to promote children who are engaged, healthy, and supported within the school community.

Abstract

Background: Nursing brings a unique lens to care of patients with pain and opioid misuse. Aims: This scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care. Design: The scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline. Data Sources: Using combined key terms (“opioid misuse,” “pain,” “nursing”) in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites. Analysis Method: Summative approach to content analysis was used to quantify and describe nursing's contribution to the literature. Results: Contributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108). Conclusion: Results provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse. Implications for Nursing: This scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.

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Background and Objectives: The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment. Research Design and Methods: Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included. Results: Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact. Discussion and Implications: The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Abstract

In the present study, we examined self-rated health as a mediator between physical health conditions (chronic diseases and functional disability) and depressive symptoms in older Chinese and Korean Americans. Using harmonized data (N = 5,063) from the Population Study of Chinese Elderly (PINE) and the Study of Older Korean Americans (SOKA), we tested direct and indirect effect models. In both groups, chronic diseases and functional disability were closely associated with negative ratings of health and symptoms of depression. Analyses with the PROCESS macro showed that the effect of chronic diseases and functional disability on depressive symptoms was mediated by self-rated health in both groups; the indirect effect was greater in the Korean American sample than in the Chinese American sample. These findings contribute to the understanding of the psychological mechanisms that underlie the mind-body connection and highlight the potential importance of subjective health assessment as a useful tool for health promotion.

Abstract

Severe maternal morbidity (SMM) is a composite outcome measure that indicates serious, potentially life-threatening maternal health problems. There is great interest in defining SMM using administrative data for surveillance and research. In the United States, one common way of defining SMM at the population level is an index developed by the Centers for Disease Control and Prevention. Modifications to this index (e.g., exclusion of maternal blood transfusion) have been proposed; some research defines SMM using an index introduced by Bateman et al. (Obstet Gynecol. 2013;122(5):957-965). Birth certificate data are also increasingly being used to define SMM. We compared commonly used US definitions of SMM among all California births (2007-2012) using the kappa (κ) statistic and other measures. We also evaluated agreement between maternal morbidity fields on the birth certificate as compared with health insurance claims data. Concordance between the 7 definitions of SMM analyzed was generally low (i.e., κ < 0.41 for 13 of 21 two-way comparisons). Low concordance was particularly driven by the presence/absence of transfusion and claims data versus birth certificate definitions. Low agreement between administrative data-based definitions of SMM highlights that results can be expected to differ between them. Further research on validity of SMM definitions, using more fine-grained data sources, is needed.

Abstract

The situation-specific theory of heart failure (HF) self-care, developed in 2008 and revised in 2016 is used worldwide by clinicians and researchers. Central to this theory is the description of self-care as a naturalistic decision-making process involving the choice of behaviors that maintain physiologic stability (maintenance), symptom perception, and the response to symptoms when they occur (management).

Abstract

Background Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. Objective To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. Methods This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015–2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. Results Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00+0.08h and 6.84+0.10h, and number of PVT lapses were 5.5+0.5 and 5.7+0.7 for GM and ICU, respectively (all P >.05). KSS was 4.8+0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12AM–6AM (2.6 vs 1.7, P < .001) and 6AM–12PM (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P, .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). Conclusions Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.

Abstract

Objective: To determine whether selected genes and plasma markers involved in energy homeostasis are associated with sleep disruption or duration in adults with HIV/AIDS. Methods: A sample of 289 adults with HIV/AIDS wore a wrist actigraph for 72 h to estimate total sleep time (TST) and wake after sleep onset (WASO). Twenty-three single nucleotide polymorphisms (SNP) spanning 5 energy homeostasis genes (adiponectin [ADIPOQ], ghrelin [GHRL], leptin [LEP], peroxisome proliferator-activated receptor-alpha [PPARA], and -gamma [PPARG]) were genotyped using a custom array. Plasma markers of energy homeostasis (adiponectin, ghrelin, leptin) were measured by commercial multiplex assay. Results: After adjusting for demographic and clinical characteristics (race/ethnicity, gender, CD4 cell count, waist circumference, medications), both WASO and TST were associated with SNPs in ADIPOQ (rs182052), LEP (rs10244329, rs3828942), PPARA (rs135551, rs4253655), and PPARG (rs709151). Additional SNPs in ADIPOQ were associated with WASO (rs1501299, rs3821799, rs6773957) and TST (rs2241766). TST was also associated with SNPs in GHRL (rs26802), LEP (rs11760956), PPARA (rs135547, rs8138102, rs4253776), and PPARG (rs12490265, rs796313). Many covariate-adjusted associations involved a significant interaction with markers of HIV (viral load, years since diagnosis). Among plasma markers, higher adiponectin was associated with less WASO, higher ghrelin and glucose levels with shorter TST, and higher leptin with longer TST. Conclusions: Replication of SNPs in all five genes and three plasma markers of energy homeostasis were associated with objective sleep measures. HIV disease influenced many of the associations. Findings strengthen evidence for associations between energy homeostasis genetics and poor sleep, and provide direction for pharmacological intervention research.

Abstract

Background: Arterial stiffness and increased blood pressure variability (BPV) are important subclinical cardiovascular diseases (CVDs). Evidence is accumulating that poor sleep is associated with subclinical CVDs. The purpose of our study was to investigate how sleep was related to arterial stiffness and BPV. We also explored whether sleep moderated the association between arterial stiffness and BPV. Methods: We conducted a cross-sectional study including 78 healthy adults aged between 35 and 64 years. Variables of interest were: 1) objective seep characteristics, assessed with a wrist actigraphy for two consecutive nights; 2) arterial stiffness, measured by carotid-femoral pulse wave velocity (cfPWV); and 3) BPV, measured using an ambulatory blood pressure monitor over 24 h and estimated by average real variability. Results: Lower sleep efficiency was an independent predictor of higher cfPWV and higher systolic BPV, while longer wake after sleep onset (WASO) was an independent predictor of higher cfPWV only. In addition, cfPWV showed a positive relationship with systolic BPV, and this relationship was moderated by sleep efficiency and WASO, respectively. The relationship between cfPWV and systolic BPV became stronger among individuals who had a level of sleep efficiency lower than 84% and who had WASO higher than 67 min, respectively. Conclusion: Our study showed that poor sleep not only directly linked with arterial stiffness and BPV but also moderated the relationship between these two subclinical CVDs. These findings suggest that improving sleep quality could be a target intervention to promote cardiovascular health in clinical practice.

Abstract

Middle-aged and older persons living with HIV (PLWH) suffer from sleep distress and cognitive disorders due to HIV infection and aging. We aim to explore the relationship between sleep satisfaction and cognitive complaints, and the mediating role of anxiety and fatigue in this relationship among middle-aged and older PLWH. We used data from a multicenter cross-sectional study in China (Shanghai, Kunming, Nanning, Hengyang, and Changning) conducted in 2017. The data analysis included 435 PLWH aged 45 years and over. Multiple linear regression models showed that worse sleep satisfaction was significantly associated with lower cognitive complaints after controlling for anxiety, fatigue, demographic variables, and clinical variables (β = −0.246, p < 0.01). Both anxiety and fatigue were significant partial mediators in the relationship between sleep satisfaction and cognitive complaints. The serial multiple mediation models of sleep satisfaction–anxiety (M1)–fatigue (M2)–cognitive complaints were supported and the alternative model of sleep satisfaction–fatigue (M2)–anxiety (M1)–cognitive complaints were both supported. Our study indicates that it is important to improve sleep quality to promote cognitive function among Chinese middle-aged and older PLWH. Prevention and treatment programs for sleep satisfaction and cognitive function should include the assessment and reduction of fatigue and anxiety.

Abstract

Introduction: Sixty million Latinxs make up 26.4% of all COVID-19 cases in the United States. It is uncertain whether behaviors and beliefs of immunizations among Latinxs is influenced by social determinants of health. The purpose of this study was to examine how social determinants of health predict COVID-19 behaviors and beliefs toward immunization among Latinxs. Methods: In this exploratory study, 11 chapters from the National Association of Hispanic Nurses collaborated to recruit participants. The CDC National 2009 H1N1 Flu Survey was adapted to measure behaviors and beliefs about immunizations of COVID-19. The Health Access Survey was used to measure social determinants of health. Instruments were available in both Spanish and English. Results: Participants (n=228) with higher education and health insurance tended to have less worry about taking the vaccine. Access to resources and practicing COVID-19 protective factors was positively associated. Alternative medicine and use of COVID-19 protective factors were negatively associated. Exposure to drugs and violence was associated with a decrease in likelihood to pursue a vaccine. Conclusions: Latinx need education about COVID-19 and vaccinations. Access to health care services must be available. Results highlight the importance of careful measurement when assessing social determinants of health among Latinx.

Abstract

Sixty million Latinxs make up 26.4% of all COVID-19 cases in the United States. It is uncertain whether behaviors and beliefs of immunizations among Latinxs is influenced by social determinants of health. The purpose of this study was to examine how social determinants of health predict COVID-19 behaviors and beliefs toward immunization among Latinxs.

Abstract

OBJECTIVE: "Diminishing returns" of socioeconomic status (SES) suggests that higher SES may not confer equivalent health benefits for ethnic minority individuals as compared to White individuals. Little research has tested whether diminishing returns also affects Native Americans. The objective of this study was to determine whether higher SES is associated with lower diabetes risk and longer gestational length in both Native American and White women, and whether SES predicts gestational length indirectly via diabetes risk. METHOD: A sample of 674,014 Native American and White women was drawn from a population-based California cohort of singleton births (2007-2012). Education, public health insurance status, gestational length, and diabetes diagnosis were extracted from a state-maintained birth cohort database. Covariates were age, health behaviors, pregnancy variables, residence rurality, and prepregnancy body mass index. RESULTS: In logistic regression models, the race by SES interaction (both education and insurance status) was associated with diabetes risk. Compared to high-SES White women, high- and low-SES Native American women had highest and equivalent diabetes risk. In path analyses, the race by SES interaction indirectly predicted gestational length through diabetes, ps < .001. For White women, an indirect effect of diabetes was detected, ps < .001, such that higher SES was associated with reduced risk for diabetes and thus longer gestational length. For Native American women, no indirect effect was detected, ps > .067. CONCLUSIONS: Among Native American women, higher SES did not confer protection against diabetes or shorter gestational length. These findings are consistent with the diminishing returns of SES phenomenon. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Abstract

As a humanistic, patient-centered approach to medicine becomes more accepted, physicians are moving from a purely objective, systematic approach to medicine toward a more holistic approach adapted to individual patients and their values and beliefs. While doctors are often uncomfortable discussing religion and spirituality with patients, some patients may actually benefit from the integration of these beliefs into the treatment process. While the terms are often used interchangeably, “religion” and “spirituality” have different meanings; religion refers to an organized system of beliefs, while spirituality relates to how individuals seek and express meaning in life through their connections to the self, others, nature, and the sacred. Religion or spirituality can improve treatment outcomes by providing patients with a more positive perspective, a greater sense of purpose, and healthier coping strategies. Prayer and meditation can inspire the relaxation response, which can improve many health indicators. The HOPE Questions for Spiritual Assessment and the FICA Spiritual History Tool are two methods that can be used to assess patients’ attitude toward the spiritual and how treatment should acknowledge these beliefs. Medical humanism encompasses many of these practices, because it is based on the idea that the physician should focus on the whole patient, including patients’ religious or spiritual beliefs.

Abstract

Excessive and prolonged stress can result in physician burnout. Burnout can compromise a physician’s ability to effectively meet the needs of patients, while also having adverse effects on personal health and well-being. Physicians are exposed to a tremendous number of stressors that arise from factors such as time and resource constraints, the complex hierarchy among medical professionals, malpractice claims, and “difficult” patients and treatments. Although burnout is currently considered to be mostly due to external causes, protective mechanisms that physicians can employ to shield themselves are explored. Hans Selye’s model of the general adaptation syndrome is one means that individuals cope with stress, along with Richard Lazarus’s transactional model of stress. Other coping strategies include problem-based coping, the ABC technique, and meditation and mindfulness. Several maladaptive responses may temporarily offer relief but can in the long run prove to be damaging. Finally, online and other digital stress-reduction programs are explored.

Abstract

Background: The Republic of Liberia has had major disruptions to the education of its health care cadres. Post Ebola, the Resilient and Responsive Health Systems (RRHS) initiative began a new era of capacity building with the support of PEPFAR and HRSA. Nursing and Midwifery serve as the largest healthcare cadres in Liberia. The national nursing and midwifery curricula were overdue for the regulated review and revisions.Methods: The Science of Improvement was used as the framework to accomplish this multilateral activity. The Institute for Healthcare Improvement's (IHI) stages of improvement included: 1) Forming the team, 2) Setting the aims, 3) Establishing measures, 4) Selecting measures, 5) Testing changes, 6) Implementing changes, and 7) Spreading changes. These stages served as the blueprint for the structures and processes put into place to accomplish this national activity.Findings: The RN, Bridging, and BScM curricula all had redundant content that did not reflect teaching pedagogy and health priorities in Liberia. Courses were eliminated or reconfigured and new courses were created. Development of Nursing and Midwifery Curricular Taskforces were not as successful as was hoped. Two large stakeholder meetings ensured that this was the curricula of the Liberian faculty, deans and directors, and clinical partners. Monitoring and evaluation tools have been adopted by the Liberian Board for Nursing and Midwifery to serve as another improvement to check that the new curricula are being implemented and to identify gaps that may require future cycles of change for continued quality and improvement.Conclusions: Developing trust among the multilateral partners was critical to the success of this activity. Networks have been expanded, and a proposed pilot with the Ghana Board of Nursing and Midwifery and the US academic partner will examine the feasibility of implementing electronic licensing examinations for nurses and midwives.

Abstract

Patient safety is jeopardized when healthcare services are provided by physicians who suffer from substance use disorders (SUDs). When focusing on the problem of substance abuse and dependence among physicians, certain factors inherent in the medical field, such as long hours, the high-stress nature of the work, and the ease of access to drugs, make physicians more susceptible to abusing or becoming dependent on prescription drugs and alcohol. SUDs may differ in severity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association, 2013) provides three severity specifiers: mild, moderate, and severe. Severe SUDs are also known as addictive disorders. To make matters worse, a culture of silence exists among colleagues, who often seek to protect the compromised physician from the legal consequences of abusing drugs. Luckily, the compromised physician can be provided with an intense and individualized treatment regime through physician health programs that aim for rehabilitation over termination of employment.

Abstract

Background: Young adult cancer survivors have significant work-related challenges, including interruptions to education and employment milestones, which may affect work-related goals (WRGs). The study purpose was to explore posttreatment perspectives of WRGs in a sample of young adult hematologic cancer survivors. Methods: This qualitative descriptive study used social media to recruit eligible cancer survivors (young adults working or in school at the time of cancer diagnosis). Data were collected through telephone semi-structured interviews and analyzed using directed content analysis, followed by thematic content analysis to identify themes. Findings: The sample (N = 40) were mostly female (63.5%), White (75%), and diagnosed with Hodgkin lymphoma (57.5%); most worked in professional (40%) or health care (23%) roles. The overarching theme, “Survivors’ Dilemma,” highlights a changed perspective on work-related fulfillment and financial obligations, capturing survivors’ decision-making process regarding work. Three subthemes illustrated questions that participants contemplated as they examined how their WRGs had changed: (a) Self-identity: Do I want to do this work? (b) Perceived health and work ability: Can I do this work? and (c) Financial toxicity: Can I afford to/not to do this work? Conclusions/Application to Practice: Participants experienced a state of dilemma around their WRGs, weighing areas around self-identity, perceived health and work ability, and financial toxicity. Findings suggest occupational health nurses should be aware of challenges surrounding WRGs, including how goals may change following a cancer diagnosis and treatment, and the potential stressors involved in the Survivors’ Dilemma. Occupational health nurses should assess for these issues and refer young survivors to employee and financial assistance programs, as necessary.

Abstract

To effectively diagnose and treat patients, physicians must often cooperate, coordinate, and problem-solve with other healthcare workers. Successful teams in medicine define and work toward shared goals, employ the pertinent and appropriate qualifications of each member, and establish trust in other team members. Task-shifting passes certain roles onto other team members so that physicians can focus on their key areas of responsibility. A number of medical schools have adopted interprofessional education to train today’s physicians, but there are other strategies that are also being explored. Training modules such as Crew Resource Management and TeamSTEPPSTM are being adapted to the needs of the healthcare field. High-fidelity patient simulations are being used to replicate common situations encountered by healthcare workers. Also, many medical schools are using problem-based or team-based learning practices through which students work with one another to tackle and reason through clinical scenarios.

Abstract

Objectives: Telemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes. Design: Whittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies. Setting and Participants: Primary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families. Methods: PubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020. Results: Measurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs. Conclusions and Implications: Preliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.