Publications

Abstract

About 11% of the adult global populations is estimated to be living with type 2 diabetes mellitus (T2DM) by 2040. T2DM requires people to make decisions regarding complex therapeutic regimes, to maintain their well-being and quality of life, to manage symptoms and to reduce disease complications. All these behaviours, requiring knowledge, motivation, experience, and skills, have been referred to the concept of self-care. The intricacy and multidimensionality of T2DM self-care requires a complex approach to its overall comprehension. This Embedded Mixed Method study aims to investigate the experience of self-care in Type 2 Diabetes Mellitus adult patients. It comprises a prospective observational design, and an interpretive description. Quantitative data will be collected with validated questionnaires from 300 patients at baseline and once a year for two years on: diabetes self-care, quality of life, diabetes related distress, and sleep quality. Socio-demographic and clinical data will be collected from medical records. Qualitative data will be collected using semi-structured interviews on circa 10-20 patients, at baseline and once a year for two years, analysed according to interpretive description. Quantitative and qualitative data will be analysed separately and then merged and interpreted. This study will expand our understanding of self-care in people with T2DM. The expected outcome will be a better understanding of the effect of self-care on glycaemic control and therefore clinical outcomes and costs.

Abstract

Psychological distress is prevalent among cancer patients, who may be vulnerable to distress at times of transition, such as a change in symptom experience, employment, or goal of treatment. Independently, both psychological distress and transitions impair patients’ quality of life, and together their adverse impact may be intensified. Self-management allows patients to engage in tasks that influence the disease experience and can include strategies to help mitigate distress associated with transitions. The purpose of this systematic review was to examine research on the relationship between self-management interventions and distress in adult cancer patients receiving active tumor-directed therapy. From a search of seven electronic databases, 5,156 articles were identified; however, nine studies met inclusion criteria. Our review suggested that self-management interventions may help address psychological distress in patients receiving cancer treatment but that the current evidence is not robust enough to support a definitive conclusion.

Abstract

Background: The dramatic increase in human immunodeficiency virus (HIV) infection among undergraduate students in China, especially among the male students, is alarming. This study aimed to describe sexual attitudes and behaviours and to examine the use of HIV prevention services and related factors among male undergraduate students in Hunan, China. Methods: A cross-sectional survey was conducted from November 2017 to January 2018 among male students from three universities in Hunan, China. Self-administered questionnaires were uploaded online to collect data anonymously. HIV-related knowledge and sexual attitudes were assessed with the unified National AIDS Sentinel Surveillance Questionnaire and Sexual Attitude Scale, whereas sexual behaviours and use of HIV prevention services were examined with researcher-created questionnaires. HIV-related knowledge, sexual attitudes and behaviours, and use of HIV prevention services were described. Chi-square test and logistic regression were used to analyse the factors associated with the use of HIV prevention education services. P values ≤0.05 were considered significant. Results: Of the 1431 respondents, 1068 (74.6%; 95% CI: 72.4-76.0%) used HIV prevention education services and 105 (7.3%) took HIV testing. The openness of sexual attitudes was moderate overall. About 299 (20.9%) of this sample had active sex partners, and 49 (16.4%) of them had sex with males. The consistent use of condoms was unsatisfactory among the sexually active students, especially among those with homosexual behaviours. Participants who were older in age (OR: 0.77, 95% CI: 0.70-0.86), who were university seniors (OR: 0.80, 95% CI: 0.70-0.91), who drank alcohol (OR: 0.71, 95% CI: 0.55-0.93), and who had open attitude towards paid sex (OR: 0.72, 95% CI: 0.54-0.95), were less likely to use HIV prevention education services. Conclusions: Although male undergraduate students show open attitude to premarital sex and engage in risky sexual behaviours, their use of HIV prevention education services is unsatisfactory, particularly in terms of HIV testing. More comprehensive and specific education on HIV prevention and testing services should be designed and offered on campus.

Abstract

Background: Some, but not all, studies report associations between shift work and hypertension, suggesting that particular subgroups may be at risk. We examined moderating effects of sleep duration and circadian preference on the relationship between shift work and new blood pressure (BP) medicine use at follow-up. Methods and Results: Baseline and 5-year follow-up data from the UK Biobank cohort (N=9200) were used to generate logistic regression models for shift workers and nonshift workers. The moderating effects of sleep duration (short ≤6 hours; adequate 7–8 hours; long ≥9 hours) and circadian preference (morning “larks;” intermediate; evening “owls”) at baseline were examined with new BP medicine use at follow-up, adjusting for age, sex, race, education, employment, urban/rural, cardiovascular disease family history, depression, alcohol intake, physical activity, diet, smoking, and body mass index. The sample was predominately middle aged (55.3±7.4), female (57.3%), and white (97.9%). Most reported adequate sleep duration (7–8 hours, 73.7%) and were intermediate type (65.3%); 8.0% were shift workers at baseline. Only 6.5% reported new BP medicine use at follow-up. Short sleep duration was a significant moderator of new BP medicine use in shift workers. Among short sleepers, shift workers had a 2.1-fold increased odds of new BP medicine use compared with nonshift workers (odds ratio=2.08, 95% CI=1.21–3.58, P=0.008). In those reporting adequate (odds ratio=0.82, 95% CI=0.54–1.25, P=0.35) and long sleep (odds ratio=0.64, 95% CI=0.11–3.54, P=0.60), this relationship was protective but nonsignificant. Interaction between circadian preference and shift work on BP medicine use was nonsignificant. Conclusions: Shift workers with short sleep duration may be at risk for hypertension.

Abstract

BACKGROUND A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, −0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, −0.45 hours; noninferiority margin, −0.5 hours; P=0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, −0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P=0.10). CONCLUSIONS This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established.

Abstract

Declining national rates of current tobacco use to an all-time low of 15.1% represents a public health victory. Undermining this progress, however, are smoking rates of up to 50% among high-risk, low-income populations. Current FDA-approved treatments for nicotine dependence are ineffective with between 70-95% of treatment-seekers relapsing within the first year of attempted abstinence. Thus, identification of novel intervention targets to optimize response to currently available treatments for nicotine dependence is a critical next step. One such target may be sleep insomnia. Insomnia is a clinically verified nicotine withdrawal symptom but, to date, addressing insomnia or other sleep disturbance symptoms as an adjunctive smoking cessation therapy has yet to be fully considered.To this end, this manuscript presents a narrative review of: (1) sleep continuity and architecture in smokers versus nonsmokers; (2) effects of nicotine abstinence on sleep; (3) possible mechanisms linking sleep with smoking cessation outcomes; (4) plausible adjunctive sleep therapies to promote smoking cessation; (5) possible treatments for unhealthy sleep in smokers; and (6) directions for future research.Taken together, this will provide conceptual support for sleep therapy as an adjunctive treatment for smoking cessation. Implications:This narrative literature review presents a comprehensive discussion of the relationship between habitual sleep and cigarette smoking.The extent to which unhealthy sleep in smokers may be a viable intervention target for promoting response to smoking cessation treatment is considered. Ultimately, this review provides conceptual support for sleep therapy as an adjunctive treatment for smoking cessation.

Abstract

The sun rises and sets over the earth in a predictable pattern. This pattern has existed for billions of years and has influenced the behavior of all living things. Behavioral rhythms have aligned with these light-dark rhythms and conferred an evolutionary advantage. Humans have adapted to the light-dark cycle so that activity occurs during the day and rest occurs during the night. Increased visibility afforded by daylight optimizes foraging and safety while being active. Reduced visibility during the night optimizes sleeping and fasting. Daily rhythms, such as light-dark, are known as circadian rhythms from the Latin words “circa,” for about, and “dias,” for a day. Physiological processes rely on predictable circadian rhythms. These processes include sleeping and waking, cardiac function, such as heart rate and blood pressure, and metabolic processes, such as glucose, lipid, and energy metabolism. Disrupting circadian rhythms can profoundly impact cardiometabolic health and well-being. Poor cardiometabolic health can also disrupt the circadian system. This chapter will briefly introduce the cardiometabolic syndrome, the circadian system, circadian disruption, and social jetlag as a form of circadian disruption.

Abstract

Background: Higher socioeconomic status (SES) has less impact on cardio-metabolic disease and preterm birth risk among Black women compared to White women, an effect called “diminishing returns.” No studies have tested whether this also occurs for pregnancy cardio-metabolic disease, specifically preeclampsia, or whether preeclampsia risk could account for race-by-SES disparities in birth timing. Methods: A sample of 718,604 Black and White women was drawn from a population-based California cohort of singleton births. Education, public health insurance status, gestational length, and preeclampsia diagnosis were extracted from a State-maintained birth cohort database. Age, prenatal care, diabetes diagnosis, smoking during pregnancy, and pre-pregnancy body mass index were covariates. Results: In logistic regression models predicting preeclampsia risk, the race-by-SES interaction (for both education and insurance status) was significant. White women were at lower risk for preeclampsia, and higher SES further reduced risk. Black women were at higher risk for preeclampsia, and SES did not attenuate risk. In pathway analyses predicting gestational length, an indirect effect of the race-by-SES interaction was observed. Among White women, higher SES predicted lower preeclampsia risk, which in turn predicted longer gestation. The same was not observed for Black women. Conclusions: Compared to White women, Black women had increased preeclampsia risk. Higher SES attenuated risk for preeclampsia among White women, but not for Black women. Similarly, higher SES indirectly predicted longer gestational length via reduced preeclampsia risk among White women, but not for Black women. These findings are consistent with diminishing returns of higher SES for Black women with respect to preeclampsia.

Abstract

Background: Hospital at home (HaH) is a model of care that provides acute-level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. Objectives: This study examined facilitators and barriers to implementation of an HaH program. Design: A HaH program that included a 30-day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. Setting: Large urban academic health system. Participants: Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). Results: To facilitate successful development and implementation of a high-quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work-arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. Conclusion: Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships. J Am Geriatr Soc 67:588–595, 2019.

Abstract

Aim: This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier. Design: Discussion paper. Data Sources: Research methods papers addressing cross-language research issues published between 2000–2017. Implications for Nursing: Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into “big data” systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes. Conclusion: Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research. Impact: This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

Abstract

Older people living with HIV (OPLWH) have higher rates of substance use (tobacco, alcohol and other drugs) than their HIV-negative peers. Addressing health care needs of OPLWH who use substances is more challenging than for those who do not: they are highly impacted by comorbid conditions, substance use can interact with other medications (including antiretroviral therapy-ART) and reduce their effectiveness, and substance use has been associated with reduced adherence to ART and increased risky behaviors (including sexual risks). People who use substances also suffer disparities along the HIV continuum of care, resulting in lower viral suppression rates and poorer health outcomes. They are especially impacted by stigma and stress, which have implications for HIV treatment and care. Recommendations for health care providers working with OPLWH who use substances include: 1) the need to screen and refer for multiple associated conditions, and 2) training/continuing education to enhance care management and maximize health outcomes.

Abstract

Incorporating biologically based data into symptom science research can contribute substantially to understanding commonly experienced symptoms across chronic conditions. The purpose of this literature review was to identify functional polymorphisms associated with common symptoms (i.e., pain, sleep disturbance, fatigue, affective and cognitive symptoms) with the goal of identifying a parsimonious list of functional genetic polymorphisms with evidence to advocate for their inclusion in symptom science research. PubMed was searched to identify genes and functional polymorphisms associated with symptoms across chronic conditions, revealing eight functional genetic polymorphisms in seven different genes that showed evidence of association with at least three or more symptoms and/or symptom clusters: BDNF rs6265, COMT rs4680, FKBP5 rs3800373, IL-6 rs1800795, NFKB2 rs1056890, SLC6A4 5-HTTLPR+rs25531, and TNFA rs1799964 and rs1800629. Of these genes, three represent protein biomarkers previously identified as common data elements for symptom science research (BDNF, IL-6, and TNFA), and the polymorphisms in these genes identified through the search are known to impact secretion or level of transcription of these protein biomarkers. Inclusion of genotype data for polymorphisms offers great potential to further advance scientific knowledge of the biological basis of individual symptoms and symptom clusters across studies. Additionally, these polymorphisms have the potential to be used as targets to optimize precision health through the identification of individuals at risk for poor symptom experiences as well as the development of symptom management interventions.

Abstract

Self-weighing may promote attainment and maintenance of healthy weight; however, the natural temporal patterns and factors associated with self-weighing behavior are unclear. The aims of this secondary analysis were to (1) identify distinct temporal patterns of self-weighing behaviors; (2) explore factors associated with temporal self-weighing patterns; and (3) examine differences in percent weight changes by patterns of self-weighing over time. We analyzed electronically collected self-weighing data from the Health eHeart Study, an ongoing longitudinal research study coordinated by the University of California, San Francisco. We selected participants with at least 12 months of data since the day of first use of a WiFi- or Bluetooth-enabled digital scale. The sample (N = 1041) was predominantly male (77.5%) and White (89.9%), with a mean age of 46.5 ± 12.3 years and a mean BMI of 28.3 ± 5.9 kg/m2 at entry. Using group-based trajectory modeling, six distinct temporal patterns of self-weighing were identified: non-users (n = 120, 11.5%), weekly users (n = 189, 18.2%), rapid decliners (n = 109, 10.5%), increasing users (n = 160, 15.4%), slow decliners (n = 182, 17.5%), and persistent daily users (n = 281, 27.0%). Individuals who were older, female, or self-weighed 6–7 days/week at week 1 were more likely to follow the self-weighing pattern of persistent daily users. Predicted self-weighing trajectory group membership was significantly associated with weight change over time (p <.001). In conclusion, we identified six distinct patterns of self-weighing behavior over the 12-month period. Persistent daily users lost more weight compared with groups with less frequent patterns of scale use.

Abstract

Deregulation of the circadian system in humans and animals can lead to various adverse reproductive outcomes due to genetic mutations and environmental factors. In addition to the clock, lipid metabolism may also play an important role in influencing reproductive outcomes. Despite the importance of the circadian clock and lipid metabolism in regulating birth timing few studies have examined the relationship between circadian genetics with lipid levels during pregnancy and their relationship with preterm birth (PTB). In this study we aimed to determine if single nucleotide polymorphisms (SNPs) in genes from the circadian clock and lipid metabolism influence 2nd trimester maternal lipid levels and if this is associated with an increased risk for PTB. We genotyped 72 SNPs across 40 genes previously associated with various metabolic abnormalities on 930 women with 2nd trimester serum lipid measurements. SNPs were analyzed for their relationship to levels of total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL) and triglycerides (TG) using linear regression. SNPs were also evaluated for their relationship to PTB using logistic regression. Five SNPs in four genes met statistical significance after Bonferroni correction (p < 1.8 × 10-4) with one or more lipid levels. Of these, four SNPs were in lipid related metabolism genes: rs7412 in APOE with total cholesterol, HDL and LDL, rs646776 and rs599839 in CELSR2-PSRC1-SORT1 gene cluster with total cholesterol, HDL and LDL and rs738409 in PNPLA3 with HDL and TG and one was in a circadian clock gene: rs228669 in PER3 with TG. Of these SNPs only PER3 rs228669 was marginally associated with PTB (p = 0.02). In addition, PER3 rs228669 acts as an effect modifier on the relationship between TG and PTB.

Abstract

Background/Objectives: To describe the design, procedures, and cohort for the Better ASsessment of ILlness -(BASIL) study, which is conducted to develop and test new delirium severity measures, compare them with existing measures, and examine related clinical outcomes. Methods: Prospective cohort study with 1 year follow-up of study participants at a large teaching hospital in Boston, Massachusetts. After brief cognitive testing and the Delirium Symptom Interview, delirium and delirium severity were rated daily in the hospital using the Confusion Assessment Method (CAM) and CAM-Severity score, the Delirium Rating Scale-Revised-98 (DRS-R-98), and the Memorial Delirium Assessment Scale (MDAS). Other key study variables included comorbidity, physical function (basic and instrumental activities of daily living [ADL]), ratings of subjective health and well-being, and clinical outcomes (length of stay, 30 day rehospitalization, nursing home admission, healthcare utilization). Follow-up interviews occurred at 1- and 12-month with patients and families. In 42 patient interviews, inter-rater reliability for key variables was assessed. Results: Of 768 eligible patients approached, 469 were screened and 352 enrolled, yielding an overall study response rate of 67% for potentially eligible participants. The mean participant was 80.3 years old (SD 6.8) and 203 (58%) were female. The majority of patients were medically complex with Charlson Comorbidity Scores ≥2 (192 patients, 55%), and 102 (29%) met criteria for dementia. Inter-rater reliability assessments (n = 42 pairs) were high for overall ratings of presence or absence of delirium by CAM (κ = 1.0), delirium severity by DRS-R-98 and MDAS (weighted kappa, κ = 1.0 for each) and for ADL impairment (κ = 1.0). For eligible participants at each time point, 278 out of 308 (90%) completed the 1-month follow-up and 132 out of 256 (53%) have completed the 12-month follow-up to date, which is still in progress. Among those who completed interviews, there was only 1-3% missing data on most major outcomes (delirium, basic ADL, and readmission). Conclusion: The BASIL study presents an innovative effort to advance the conceptualization and measurement of delirium severity. Unique strengths include the diverse cohort with complete high quality data and longitudinal follow-up, along with detailed collection of multiple delirium measures daily during hospitalization.

Abstract

Background: Annually, over 65,000 persons are diagnosed with head and neck cancer in the United States. During treatment, up to 50% of patients become severely symptomatic with pain, fatigue, mouth sores, and inability to eat. Long term complications are lymphedema, fibrosis, dysphagia, and musculoskeletal impairment. Patients' ability to perform daily activities and to interact socially may be impaired, resulting in poor quality of life. A pragmatic, clinically useful assessment is needed to ensure early detection and intervention for patients to report symptoms and functional limitations over time. We developed the Electronic Patient Visit Assessment (ePVA) that enables patients to report 42 symptoms related to head and neck cancer and 17 limitations of functional status. This manuscript reports (I) the development of the ePVA, (II) the content validity of the ePVA, and (III) the usability and reliability of the ePVA.Methods: Usability was evaluated using the "Think Aloud" technique to guide the iterative process to refine the ePVA based on participants' evaluations. After signing the informed consent, 30 participants with head and neck cancer completed the ePVA using digital tablet devices while thinking aloud about ease of use. All patient conversations were recorded and professionally transcribed. Reliability of the ePVA symptom and functional limitation measures was estimated using the Kuder-Richardson test. Convergent validity of the ePVA was evaluated using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 global QoL/health scale. Transcribed qualitative data were analyzed using directed content analysis approach. Quantitative analyses consisted of descriptive statistics and correlation analyses.Results: Among participants, 90% strongly agreed or agreed that the ePVA system was easy to use and 80% were very satisfied. Only minor usability problems were reported due to formatting and software "bugs". Reporting of usability problems decreased in frequency over the study period and no usability problems were reported by the last 3 participants who completed the ePVA. Based on participants' suggestions during the iterative process, refinement of the ePVA included increased touch sensitivity of the touch screen technology and customized error messages to improve ease of use. The ePVA also recorded patient reported symptoms (mouth symptoms: 93%, fibrosis: 60%, fatigue: 60%). The ePVA demonstrated acceptable reliability (alpha =0.82-0.85) and convergent validity (ePVA total number of reported symptoms and function limitations was negatively correlated with EORTC QLQ-C30 global QOL/health scale: r=-0.55038, P<0.01).Conclusions: The ePVA was rigorously developed, accepted by patients with satisfaction, and demonstrated acceptable reliability and convergent validity. Future research will use data generated by the ePVA to determine the impact of symptom trajectories on functional status, treatment interruptions and terminations, and health resource use in head and neck cancer.

Abstract

Background: Abnormal blood glucose (BG) levels during hematopoietic cell transplantation (HCT) are associated with increased infections, delayed engraftment, and prolonged hospitalization, though little is known about these associations. Materials and Methods: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 � 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Results: We retrospectively evaluated mean BG levels in the week prior to HCT and subsequent outcomes for 852 HCTs at our hospital from 1/2009 � 12/2013 pertaining to 745 patients. Outcomes included infections (pneumonia, C. difficile, positive cultures, administration of antimicrobials, or neutropenic fever), time-to-engraftment (TTE), and quality indicators (30- and 90-day readmission rates [RR] and median length-of-stay [LOS]). Conclusion: Pre-HCT BG trends may be a prognostic biomarker for adverse outcomes, and thus can help improve quality of care for HCT patients.

Abstract

Background: Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record's impact on these dimensions of nurses’ work. Objective: The purpose of this review was to synthesize the literature on the electronic health record's impact on nurses’ cognitive work. Design: Integrative review. Data sources: MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO. Review methods: The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies. Results: Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians’ cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians’ ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses’ work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful. Conclusion: The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.

Abstract

Background: This study explored nursing home (NH) personnel perceptions of the National Healthcare Safety Network (NHSN). Methods: NHs were purposively sampled based on NHSN enrollment and reporting status, and other facility characteristics. We recruited NH personnel knowledgeable about the facility's decision-making processes and infection prevention program. Interviews were conducted over-the-phone and audio-recorded; transcripts were analyzed using conventional content analysis. Results: We enrolled 14 NHs across the United States and interviewed 42 personnel. Six themes emerged: Benefits of NHSN, External Support and Motivation, Need for a Champion, Barriers, Risk Adjustment, and Data Integrity. We did not find substantive differences in perceptions of NHSN value related to participants' professional roles or enrollment category. Some participants from newly enrolled NHs felt well supported through the NHSN enrollment process, while participants from earlier enrolled NHs perceived the process to be burdensome. Among participants from non-enrolled NHs, as well as some from enrolled NHs, there was a lack of knowledge of NHSN. Conclusions: This qualitative study helps fill a gap in our understanding of barriers and facilitators to NHSN enrollment and reporting in NHs. Improved understanding of factors influencing decision-making processes to enroll in and maintain reporting to NHSN is an important first step towards strengthening infection surveillance in NHs.

Abstract

Background: Awareness of disease status has been identified as a factor in the treatment decision-making process. Women with recurrent ovarian cancer are facing the challenge of making treatment decisions throughout the disease trajectory. It is not understood how women with ovarian cancer perceive their disease and subsequently make treatment decisions. Purpose: The purpose of this phenomenological study was to understand the lived experience of women with recurrent ovarian cancer, how they understood their disease and made their treatment decisions. Methods: A qualitative design with a descriptive phenomenological method was used to conduct 2 in-depth interviews with 12 women (n = 24 interviews). Each interview was ∼60 minutes and was digitally recorded and professionally transcribed. Data collection focused on patients' understanding of their disease and how patients participated in treatment decisions. A modified version of Colaizzi's method of phenomenological reduction guided data analysis. Results: Three themes emerged to describe the phenomenon of being aware of disease status: (1) perceiving recurrent ovarian cancer as a chronic illness, (2) perceived inability to make treatment decisions, and (3) enduring emotional distress. Conclusions and Implications: This study revealed how 12 women conceptualized recurrent ovarian cancer as a chronic disease and their perceived inability to make treatment decisions because of lack of information and professional qualifications, resulting in enduring emotional distress. Future research should replicate the study to confirm the persistence of the themes for racially, ethnically, and religiously diverse patient samples and to improve understanding of awareness of disease status and decision-making processes of patients.

Abstract

The aim of this study was to evaluate the effectiveness of an innovative pediatric interprofessional education clinical experience using oral-systemic health as the clinical population example for improving the self-reported interprofessional competencies of family nurse practitioner, dental, and medical students. The objectives of the interprofessional experience were for students to apply pediatric oral health assessment, identify the pediatric oral-systemic connection, and practice a team-based approach to improve oral-systemic outcomes. In spring 2015, fall 2015, and spring 2016, a total of 162 family nurse practitioner, dental, and medical students participated in this interprofessional experience at Bellevue Pediatric Outpatient Clinics together with a pediatric dental resident. Team members collaborated in reviewing the patient chart, taking the patient's medical and dental history, performing an oral assessment, applying fluoride varnish, and providing education and anticipatory guidance. The Interprofessional Collaborative Competency Attainment Survey (ICCAS) was used as a pretest and posttest to evaluate the degree to which students perceived changes in their attitudes about interprofessional competencies following the learning experience. In the results, all students had improved mean scores from pretest to posttest after the experience, and these changes were statistically significant for all students: nurse practitioner (p<0.01), dentistry (p<0.01), and medicine (p<0.001). The mean change from pretest to posttest was statistically significant for each of the six interprofessional competency domains (p<0.01). In both pediatric dental and primary care settings, the changes from pre- to posttest were significant (p<0.001). The experience was similarly effective for all groups of students in increasing their attitudes about interprofessional collaboration. These findings suggest that a clinical approach can be an effective strategy for helping health professions students develop interprofessional competence.