Good Things Don't Always Come in Small Packages: Comprehensive Care of Patients With Class 3 Obesity: An Integrative Review.

The epidemic of obesity and morbid obesity is straining the American health care system's ability to provide quality patient care. Patients with Class 3 (also referred to as morbid or severe) obesity require specialized equipment, unique approaches in the delivery of care, and understanding of the biopsychosocial pathophysiologic mechanisms underlying their condition. This article defines Class 3 obesity, its pathophysiology, and discusses issues that arise when providing quality care of these individuals including safe patient handling, right-sized equipment, and empathetic interpersonal care. We also discuss skin and wound care issues associated with Class 3 obesity.

Factors Affecting Psychosocial Adjustment in Persons With a Recent Ostomy.

PURPOSE: The aim of this study was to examine the influence of personal and clinical factors on psychosocial adjustment in persons living with an ostomy for less than 1 year. DESIGN: A cross-sectional survey. SUBJECTS AND SETTING: The study sample comprised 183 adult individuals who had a colostomy, ileostomy, or urostomy for less than 1 year, residing in the Northeastern United States. METHODS: Data were collected from May through November 2018 using 2 instruments: a sociodemographic questionnaire and the Ostomy Adjustment Inventory-23 (OAI-23). The OAI-23 items measured 4 psychosocial subscales: acceptance, anxious preoccupation, social engagement, and anger. Data were analyzed using analysis of variance, multivariate analysis of variance, Cramer's V correlations, and multiple regression. RESULTS: Univariate analysis indicated that factors influencing psychosocial adjustment to an ostomy include age, assistance with care, educational background, stomal type, body mass index, ostomy height, preoperative education, and stoma siting. Multivariate analysis of variance identified that those who reported independence with ostomy care experienced higher levels of adjustment in all areas of the OAI-23. CONCLUSIONS: Findings from this study may assist nurses and other care providers to better understand the physical and emotional needs of those with ostomies and to identify interventions to promote optimal health in this population.

SOCIAL BULLYING IN NURSING AND HEALTH SCIENCES ACADEMIA: A QUALITATIVE STUDY.

Background: Academic social bullying in nursing and health professions schools is an understudied area yet emerging research shows it is prevalent. Purpose: This qualitative study derived from two larger quantitative studies targeting the development and validation of an instrument measuring academic social bullying and whose purpose was to understand the phenomenon in greater depth from narrative comments. Methods: Survey design with open ended questions was utilized to obtain content and construct validation along with reliability data for a de-novo instrument measuring academic social bullying. Over 250 nurse academics and 417 health sciences educators in baccalaureate and higher degree programs in the United States responded. This qualitative study focused on analysis of narrative comments (N = 91 nurse respondents and N = 89 health sciences faculty respondents, respectively) provided in response to open ended questions. Results: Five qualitative themes emerged from narrative content analysis. Qualitative themes approximated the construct-validated factors in the quantitative studies but also expanded on them. The themes included: Bullying experiences, faculty issues, issues of academia, student bullying of faculty, and general comments about bullying. Conclusion: Academic social bullying is a significant phenomenon for nursing and health sciences educators affecting faculty well-being. This study's qualitative findings can help enrich understanding of the problem and augment future quantitative and qualitative studies with the hope of developing targeted interventions.

Psychometric Development of an Instrument Measuring Social Bullying in Nursing Academia: Item Development and Content Validation.

BACKGROUND: Social bullying in academic nursing schools is an understudied area, yet extant research shows it is prevalent. PURPOSE: The purpose of this study was to generate a formal definition for academic social bullying and content validate an instrument measuring it in academic nursing. METHODS: Classic psychometric theory and survey design were used to develop an instrument measuring academic social bullying. Extensive literature review and analysis of existing instruments were conducted; 108 items indicating bullying behaviors and organizational characteristics were created. This study targeted establishing initial content validity. Forty nurse experts who had experienced or published on academic bullying were invited; 24 responded. Experts rated agreement with relevance/appropriateness of items using a Likert scale and provided comments. RESULTS: Forty items with content validity indexes near 0.80 and supportive comments were retained. A formal definition was developed from experts' feedback. CONCLUSIONS: Insights regarding differences between bullying and incivility were obtained.

Critical Connections Among Embedding of Childhood Adversity and Adult Chronic Gastrointestinal and Genitourinary Disorders: A Review of the Literature.

BACKGROUND: A gap in the literature exists demonstrating associations between adverse child experiences (ACEs) as potential a priori contributing factors and gastrointestinal (GI)/genitourinary (GU) disorders. PURPOSE: A narrative review of the literature was conducted to explore critical connections between ACEs and GI/GU disorders with a working hypothesis of a dose-responsive relationship existing among them. METHODS: A literature search was conducted using MEDLINE, Cumulative Index of Nursing and Allied Health Literature, PubMed, and Web of Science using search terms adverse childhood experiences, childhood adversity, obesity, gastrointestinal disorders, and genitourinary disorders, and secondary searches of obesity and specific GI/GU disorders (eg, irritable bowel syndrome, pelvic pain). Duplicates and articles with inappropriate focus were discarded after review. RESULTS: A total of 58 articles were included. Research identified showed that ACEs do play a role in adult GI and GU morbidities in a dose-response manner, and selected factors such as socioeconomic status, race, gender identity, and physiologic state (eg, obesity) confer higher risk. Research also suggested that genetic/epigenetic mechanisms are at play in disease occurrence, and the impact of ACEs may be mitigated with positive life experiences. CONCLUSION: Research on the relationship between ACEs and GI/GU disorders is heterogeneous, notably due to wide variations in how types of ACEs are defined and screening methods used. Despite this limitation, associations are demonstrated. Awareness of a possible correlation between ACEs and risk of GI/GU disorders has the potential to improve patient care, especially through trauma-informed strategies.

Connections Among Biologic Embedding of Childhood Adversity, Adult Chronic Illness, and Wound Care: A Review of the Literature.

Adverse childhood experiences (ACEs) biologically embed by altering brain development and influencing epigenetic mechanisms. These experiences may generate health risk factors. PURPOSE: A literature review was conducted to compare ACE-generated health risk factors with risk factors for wound development and aberrant healing, as well as to identify a gap in literature regarding critical connections between ACEs, chronic illness, and wound development/healing, with associated practice implications. METHODOLOGY: A literature search of English-language articles was conducted using the Cumulative Index of Nursing and Allied Health Literature, MEDLINE, and PubMed using the search terms adverse childhood experiences, adults, wounds, chronic disease or illness, and epigenetics. The searches yielded 561 publications regarding ACEs, chronic illness or disease, and adult; 182 for ACEs; and 547 for epigenetics and wounds. Abstracts were reviewed to remove duplicates and studies with participants who were <18 years old. Publications were reviewed for salience; those discussing the biologic plausibility of ACEs contributing to adult illnesses and associated wound development and healing were reviewed for inclusion. RESULTS: Sixty-eight (68) publications were found appropriate for review and included population-based studies; literature reviews; epidemiologic data; meta-analyses; and systematic, cross-sectional, observational, and prospective studies as singular or mixed methods designs. A substantial overlap was found in terms of risk factors generated by ACE exposure and risk factors for wound development/healing, as was a gap in the literature regarding this relationship. Epigenetic mechanisms and altered brain development are implicated in processes through which childhood adversity erodes human health. CONCLUSION: Adult health risks as a result of exposure to ACEs and critical connections with risks for wound development and disrupted wound healing via epigenetic influences are recognized in the literature. Practice implications include considering screening for the risk factor of ACEs exposure in adult patients to identify this additional risk factor and practicing patient-centered, trauma-informed care. Further research into the integrative roles of these factors is warranted.

Addressing the Perioperative Nursing Shortage Through Education: A Perioperative Imperative.

Perioperative nurse leaders are facing an unprecedented nursing shortage. Very few baccalaureate nursing programs in the United States prepare graduates for perioperative nursing, and many current perioperative nurses are retiring from practice or leaving the field for other reasons. It is a challenge for nursing administrators to fill the vacant positions because it takes several months to orient a novice perioperative nurse and it involves significant costs. This article provides current information about perioperative nurse and leader shortages, discusses the effects of the shortages on patient safety and health care facility finances, and reviews the available literature about perioperative nursing education from both an academic and health care facility administrative perspective. In addition, this article presents strategies for addressing the nursing shortage and describes implications for clinical practice, education, and research.

Attitude Isn't the Only Thing, It's Everything: Humanistic Care of the Bariatric Patient Using Donabedian's Perspective on Quality of Care.

Comprehensive care of bariatric patients is challenging. Although structural knowledge exists about safe care given correct equipment and supplies, care processes also must be humane. The literature suggests morbidly obese patients may fear the health system because of past negative experiences. The purpose of this literature review was to examine quality issues in the care of bariatric patients in light of Donabedian's structure-process-outcomes model, emphasizing process components. Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO; the criteria English language and years 2005 to 2017; and the search terms morbid obesity, obesity, bariatric, attitudes, health professionals, health clinicians, and patient care yielded 150 articles. Of those, 35 were pertinent to the review. A subsequent search using the terms Donabedian, care, and quality in MEDLINE and CINAHL resulted in 68 and 36 citations, respectively; 4 were used. When the searches were combined, no articles were identified. Findings show care providers generally understand structure aspects (knowledge or what to do) but need increased understanding of optimal care interventions (process issues or how to perform an intervention), including physical and psychological aspects. Organizations have a responsibility to ensure appropriate equipment and supportive services are available to achieve desired outcomes. Structure components will not overcome barriers or prevent complications if uncaring attitudes (processes) interfere with interpersonal interactions. Implications for clinical practice include requisite reflection on personal belief systems and empathetic understanding of precursors to morbid obesity development. Research needs to analyze what process issues are hampering quality care delivery and how to eradicate deficiencies. Health professionals can promote optimal bariatric patient outcomes by developing necessary insight and clinical wisdom. Obesity is a worldwide epidemic and those affected deserve improved care now.

Application of a modified diabetes prevention program with adolescents.

OBJECTIVE: The purpose of this study was to increase type 2 diabetes (T2DM) awareness and decrease T2DM risk factors by examining effectiveness of a modified version of the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP) with adolescents. DESIGN AND SAMPLE: A quasi-experimental one-group, pretest/posttest design was used to determine impact of the modified DPP on adolescents. Study intervention was incorporated into the health education curriculum at a public charter school and implemented over 11 weeks. Study sample included primarily African-American and Hispanic adolescents (N = 101) aged 13-18 attending the public charter school in a New Jersey urban community. MEASURES: Instrumentation included valid, reliable measures of self-efficacy for healthy eating, physical activity, food knowledge, and healthy food choices. Participants' pretest/posttest waist circumference and body mass index (BMI) were collected. RESULTS: Outcomes revealed significant (p < .001) increase in participants' food knowledge, self-efficacy for choosing healthy foods and performing physical activity, healthy food choices, and amount of weekly aerobic exercise. Reductions in BMI and waist circumference were statistically significant (p < .05). CONCLUSIONS: A modified DPP adapted for adolescents' learning needs lowered risk for T2DM. Implications for clinical practice, education, and research are posed.

Pharmacologic Impact (aka "Breaking Bad") of Medications on Wound Healing and Wound Development: A Literature-based Overview.

Patients with wounds often are provided pharmacologic interventions for their wounds as well as for their acute or chronic illnesses. Drugs can promote wound healing or substantively hinder it; some medications cause wound or skin reactions. A comprehensive review of extant literature was conducted to examine the impact of drug therapy on wound healing and skin health. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language articles published between 2000 and 2016 using the terms drugs, medications, drug skin eruptions, adverse skin reactions, wound healing, delayed wound healing, nonhealing wound, herbals, and herbal supplements. The search yielded 140 articles (CINAHL) and 240 articles (MEDLINE) for medications and wound healing. For medications and adverse skin effects, the search identified 256 articles (CINAHL) and 259 articles (MEDLINE). The articles included mostly narrative reviews, some clinical trials, and animal studies. Notable findings were synthesized in a table per pharmacological class and/or agent focusing on wound healing impact and drug-induced adverse skin reactions. The medications most likely to impair wound healing and damage skin integrity include antibiotics, anticonvulsants, angiogenesis inhibitors, steroids, and nonsteroidal anti-inflammatory drugs. Conversely, drugs such as ferrous sulfate, insulin, thyroid hormones, and vitamins may facilitate wound healing. Selected clinical practices, including obtaining a detailed medication history that encompasses herbal supplements use; assessing nutrition status especially protein blood levels affecting drug protein binding; and scrutinizing patient history and physical characteristics for risk factors (eg, atopy history) can help diminish and/or eliminate adverse integumentary outcomes. "Deprescribing" (discontinuing unnecessary medications) should be utilized when possible. Contemporary wound care clinicians must be cognizant of these mitigating clinical approaches.

Management Approaches to Stomal and Peristomal Complications: A Narrative Descriptive Study.

PURPOSE: The purpose of this study was to identify optimal interventions for selected complications based on WOC nurse experts' judgment/expertise. METHODS: A cross-sectional quantitative descriptive design with qualitative, narrative-type components was used for this study. Following validation rating of appropriateness of interventions and quantitative rankings of first-, second-, and third-line approaches, participants provided substantive handwritten narrative comments about listed interventions. Comments were organized and prioritized using frequency count. RESULTS: Narrative comments reflected the quantitative rankings of efficacy of approaches. Clinicians offered further specific suggestions regarding product use and progression of care for selected complications. CONCLUSIONS: Narrative analysis using descriptive quantitative frequency count supported the rankings of most preferred treatments of selected stomal and peristomal complications. Findings add to the previous research on prioritized approaches and evidence-based practice in ostomy care.

Systematic Reviews and Meta-Analyses - Literature-based Recommendations for Evaluating Strengths, Weaknesses, and Clinical Value.

Good quality systematic reviews (SRs) summarizing best available evidence can help inform clinical decisions, improv- ing patient and wound outcomes. Weak SRs can misinform readers, undermining care decisions and evidence-based practice. To examine the strengths and weaknesses of SRs and meta-analyses and the role of SRs in contemporary evidence-based wound care practice, and using the search terms systematic review, meta-analysis, and evidence-based practice, the authors searched Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) for important terminology and recommendations to help clinicians evaluate SRs with meta-analysis. Reputable websites, recent textbooks, and synthesized available literature also were reviewed to describe and summarize SR strengths and weaknesses. After developing a checklist for critically evaluating SR objectives, inclusion/exclusion criteria, study quality, data extraction and synthesis methods, meta-analysis homogeneity, accuracy of results, interpretation, and consistency between significant findings and abstract or conclusions, the checklist was applied to topical wound care SRs identified in Cochrane and MEDLINE searches. Best available evidence included in the SRs from 169 randomized controlled trials on 11,571 patients supporting topical intervention healing effects on burns, surgical sites, and diabetic, venous, or pressure ulcers was summarized and showed SRs and clinical trials can demonstrate different outcomes because the information/data are compiled differently. The results illustrate how evidence insufficient to support firm conclusions may still meet immediate needs to guide carefully considered clinical wound and patient care decisions while encouraging better future science.

Resilience to Social Bullying in Academia: A Phenomenological Study.

While social bullying, negative workplace behaviors, and incivility are receiving scholarly attention, no research study could be identified targeting resilience to social bullying in nursing programs. This article describes a phenomenological study that investigated resilience to social bullying. Seventeen self-identified bullied nurse faculty were audiotaped. Colaizzi's method guided data analysis. Multiple themes reflected 3 chronologic periods: during bullying, decisional phase, and after bullying. Implications for the health and well-being of nursing faculty are posed.

Pressure ulcer prevention algorithm content validation: a mixed-methods, quantitative study.

Translating pressure ulcer prevention (PUP) evidence-based recommendations into practice remains challenging for a variety of reasons, including the perceived quality, validity, and usability of the research or the guideline itself. Following the development and face validation testing of an evidence-based PUP algorithm, additional stakeholder input and testing were needed. Using convenience sampling methods, wound care experts attending a national wound care conference and a regional wound ostomy continence nursing (WOCN) conference and/or graduates of a WOCN program were invited to participate in an Internal Review Board-approved, mixed-methods quantitative survey with qualitative components to examine algorithm content validity. After participants provided written informed consent, demographic variables were collected and participants were asked to comment on and rate the relevance and appropriateness of each of the 26 algorithm decision points/steps using standard content validation study procedures. All responses were anonymous. Descriptive summary statistics, mean relevance/appropriateness scores, and the content validity index (CVI) were calculated. Qualitative comments were transcribed and thematically analyzed. Of the 553 wound care experts invited, 79 (average age 52.9 years, SD 10.1; range 23-73) consented to participate and completed the study (a response rate of 14%). Most (67, 85%) were female, registered (49, 62%) or advanced practice (12, 15%) nurses, and had > 10 years of health care experience (88, 92%). Other health disciplines included medical doctors, physical therapists, nurse practitioners, and certified nurse specialists. Almost all had received formal wound care education (75, 95%). On a Likert-type scale of 1 (not relevant/appropriate) to 4 (very relevant and appropriate), the average score for the entire algorithm/all decision points (N = 1,912) was 3.72 with an overall CVI of 0.94 (out of 1). The only decision point/step recommendation with a CVI of ≤ 0.70 was the recommendation to provide medical-grade sheepskin for patients at high risk for friction/shear. Many positive and substantive suggestions for minor modifications including color, flow, and algorithm orientation were received. The high overall and individual item rating scores and CVI further support the validity and appropriateness of the PUP algorithm with the addition of the minor modifications. The generic recommendations facilitate individualization, and future research should focus on construct validation testing.

Clinician challenges in providing health care for a morbidly obese family member: a bariatric case study.

Morbid obesity is a chronic disease affecting millions of Americans. The disorder is likely to increase in prevalence because currently one third of the American population is obese. Many factors are associated with morbid obesity, including psychological (eg, depression), physiological (eg, hypothyroidism) mechanisms, sleep disorders (eg, sleep apnea), drug therapy (antidepressants, antidiabetic agents, steroids), and genetics. Increasing numbers of morbidly obese patients are requiring critical care, presenting major challenges to professional staff across the disciplines. This manuscript presents a case study describing the experiences of a morbidly obese woman in the final years of her life from the perspective of her health professional relative. The patient typifies many of the major risk factors for morbid obesity; her story reveals many of the issues faced as she revolved in and out of the critical care and acute care system. Her substantive health problems affected multiple body systems and included hypothyroidism, congestive heart failure, hyperlipidemia, and subclinical Cushing's Syndrome, likely related to previous medical therapy (cortisone) for rheumatic fever in childhood. The case description addresses many integumentary system issues the patient experienced; skin injuries and infections that can pose serious life-threatening situations for the morbidly obese patient must be prevented or treated efficiently. Health professionals can learn a great deal and improve the care they provide by listening to morbidly obese patients.