The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases.

BACKGROUND: Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted. OBJECTIVE: To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs. DESIGN: Experimental vignette research. SETTING: Online experiment distributed via email between October and December 2020. PARTICIPANTS: Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States. METHODS: Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information. RESULTS: Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis. CONCLUSIONS: Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs. TWEETABLE ABSTRACT: Simulated experimental study found that despite having received identical clinical information, emergency nurses believed that patients displaying irritable behaviours were less likely to return to work soon and were less likely to recover than patients who displayed calm behaviour.

A Qualitative Study of Emergency Physicians' and Nurses' Experiences Caring for Patients With Psychiatric Conditions and/or Substance Use Disorders.

STUDY OBJECTIVE: Patients with psychiatric conditions and/or substance use disorders (SUDs) frequently seek care in emergency departments (EDs), where providing care for these populations can involve considerable challenges. This study aimed to develop a comprehensive data-driven model of the complex challenges and unique dynamics associated with caring for these populations in the ED, as well as the effect on patient care quality. METHODS: We conducted a preplanned topical analysis of grounded theory data obtained from semistructured interviews with 86 ED physicians and nurses from 8 hospitals in the Northeastern USA. Participants provided detailed descriptions of their experiences and challenges in caring for patients with psychiatric conditions and/or SUDs. We identified themes inductively using constant comparative analysis and developed a grounded model of physicians' and nurses' perceptions of challenges, biases, and effects on patient care. RESULTS: Emergency physicians and nurses described emotional, diagnostic, and logistical challenges that patients with psychiatric conditions and/or SUDs present. These challenges are magnified by existing health care system issues and social structures, which fuel and reinforce negative attitudes, expectations, and biases. In combination, these processes create negative health care experiences for patients, physicians, and nurses and can adversely affect patient care quality and ED staff well-being. CONCLUSION: Our findings uncover a cyclical process whereby challenges and biases associated with patients with psychiatric conditions and/or SUDs can reciprocally threaten patient care quality. Systemic changes and localized interventions are urgently needed to mitigate challenges, reduce bias, improve patient care, and improve physicians' and nurses' experiences in the ED.

COVID-19 related negative emotions and emotional suppression are associated with greater risk perceptions among emergency nurses: A cross-sectional study.

Background: As the COVID-19 pandemic began, frontline nurses experienced many emotions as they faced risks relevant to both patients (e.g., making errors resulting in patient harm) and themselves (e.g., becoming infected with COVID-19). Although emotions are often neglected in the patient safety literature, research in affective science suggests that emotions may significantly impact nurses' perceptions of risk, which can have downstream consequences. Further, the use of chronic emotion regulation strategies that are known to differ in adaptability and effectiveness (i.e., emotional suppression, reappraisal) can impact risk perceptions. Objective: To investigate the relationship between nurses' emotional experiences in response to the pandemic and their estimates of how likely they would be to experience adverse outcomes related to both patients and themselves within the next six months. Additionally, we investigated the extent to which the use of suppression and reappraisal processes to manage emotions are associated with these risk perceptions. Design: Cross-sectional survey. Setting: Online survey distributed via email to emergency nurses at eight hospitals in the northeastern United States during fall 2020. Participants: 132 emergency nurses (M age = 37.05; 81.1% Female; 89.4% White). Methods: Nurses reported the extent to which they experienced a variety of positive (e.g., hope, optimism) and negative (e.g., fear, sadness) emotions in response to the COVID-19 pandemic, and reported their perceptions of risk to both patients and themselves. Nurses also completed the Emotion Regulation Questionnaire, a measure of chronic tendencies to engage in emotional suppression and reappraisal. Immediately prior to providing data for this study, nurses completed an unrelated decision-making study. Results: Nurses' negative emotions in response to COVID-19 were associated with greater perceptions of both patient safety risks (b = 0.31, p < .001) and personal risks (b = 0.34, p < .001). The relationships between positive emotions and risk perceptions were not statistically significant (all p values > 0.66). Greater chronic tendencies to suppress emotions uniquely predicted greater perceptions of patient safety risks (b = 2.91, p = .036) and personal risks (b = 2.87, p = .040) among nurses; however, no statistically significant relationships with reappraisal emerged (all p values > 0.16). Conclusions: Understanding factors that influence perceptions of risk are important, given that these perceptions can motivate behaviours that may adversely impact patient safety. Such an understanding is essential to inform the development of interventions to mitigate threats to patient safety that emerge from nurses' negative emotional experiences and their use of different emotion regulation strategies. Tweetable abstract: Covid-related negative emotions and emotional suppression are associated with greater patient and personal risk perceptions among emergency nurses @lindamisbell @Nathan_Huff_1.

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities.

Psychological research consistently demonstrates that affect can play an important role in decision-making across a broad range of contexts. Despite this, the role of affect in clinical reasoning and medical decision-making has received relatively little attention. Integrating the affect, social cognition, and patient safety literatures can provide new insights that promise to advance our understanding of clinical reasoning and lay the foundation for novel interventions to reduce diagnostic errors and improve patient safety. In this paper, we briefly review the ways in which psychologists differentiate various types of affect. We then consider existing research examining the influence of both positive and negative affect on clinical reasoning and diagnosis. Finally, we introduce an empirically supported theoretical framework from social psychology that explains the cognitive processes by which these effects emerge and demonstrates that cognitive interventions can alter these processes. Such interventions, if adapted to a medical context, hold great promise for reducing errors that emerge from faulty thinking when healthcare providers experience different affective responses.

A qualitative investigation of the impact of coronavirus disease 2019 (COVID-19) on emergency physicians' emotional experiences and coping strategies.

STUDY OBJECTIVE: Throughout the coronavirus disease 2019 (COVID-19) pandemic, emergency physicians in the United States have faced unprecedented challenges, risks, and uncertainty while caring for patients in an already vulnerable healthcare system. As such, the pandemic has exacerbated high levels of negative emotions and burnout among emergency physicians, but little systematic qualitative work has documented these phenomena. The purpose of this qualitative investigation was to study emergency physicians' emotional experiences in response to COVID-19 and the coping strategies that they employed to navigate the pandemic. METHODS: From September 2020 to February 2021, we conducted semistructured interviews with 26 emergency physicians recruited from 2 early COVID-19 epicenters: New York City and the Metro Boston region. Interviews, coding, and analyses were conducted using a grounded theory approach. RESULTS: Emergency physicians reported heightened anxiety, empathy, sadness, frustration, and anger during the pandemic. Physicians frequently attributed feelings of anxiety to medical uncertainty around the COVID-19 virus, personal risk of contracting the virus and transmitting it to family members, the emergency environment, and resource availability. Emergency physicians also discussed the emotional effects of policies prohibiting patients' family members from entering the emergency department (ED), both on themselves and patients. Sources of physician anger and frustration included changing policies and rules, hospital leadership and administration, and pay cuts. Some physicians described an evolving, ongoing coping process in response to the pandemic, and most identified collective discussion and processing within the emergency medicine community as an effective coping strategy. CONCLUSIONS: Our findings underscore the need to investigate the effects of physicians' pandemic-related emotional stress and burnout on patient care. Evidence-based interventions to support emergency physicians in coping with pandemic-related trauma are needed.

Validation of a brief scale to assess ambulatory patients' perceptions of reading visit notes: a scale development study.

OBJECTIVES: To develop and evaluate the validity of a scale to assess patients' perceived benefits and risks of reading ambulatory visit notes online (open notes). DESIGN: Four studies were used to evaluate the construct validity of a benefits and risks scale. Study 1 refined the items; study 2 evaluated underlying factor structure and identified the items; study 3 evaluated study 2 results in a separate sample; and study 4 examined factorial invariance of the developed scale across educational subsamples. SETTING: Ambulatory care in three large health systems in the USA. PARTICIPANTS: Participants in three US health systems who responded to one of two online surveys asking about benefits and risks of reading visit notes: a psychometrics survey of primary care patients, and a large general survey of patients across all ambulatory specialties. Sample sizes: n=439 (study 1); n=439 (study 2); n=500 (study 3); and n=250 (study 4). PRIMARY AND SECONDARY OUTCOME MEASURES: Questionnaire items about patients' perceived benefits and risks of reading online visit notes. RESULTS: Study 1 resulted in the selection of a 10-point importance response option format over a 4-point agreement scale. Exploratory factor analysis (EFA) in study 2 resulted in two-factor solution: a four-item benefits factor with good reliability (alpha=0.83) and a three-item risks factor with poor reliability (alpha=0.52). The factor structure was confirmed in study 3, and confirmatory factor analysis of benefit items resulted in an excellent fitting model, X2(2)=2.949; confirmatory factor index=0.998; root mean square error of approximation=0.04 (0.00, 0.142); loadings 0.68-0.86; alpha=0.88. Study 4 supported configural, measurement and structural invariance for the benefits scale across high and low-education patient groups. CONCLUSIONS: The findings suggest that the four-item benefits scale has excellent construct validity and preliminary evidence of generalising across different patient populations. Further scale development is needed to understand perceived risks of reading open notes.

Correction: OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes.

[This corrects the article DOI: 10.2196/13876.].

Sharing Psychotherapy Notes with Patients: Therapists' Attitudes and Experiences.

Evidence suggests that the practice of sharing clinicians' notes with patients via online patient portals may increase patient engagement and improve patient-clinician relationships while requiring little change in providers' workflow. Authors examined clinical social workers' experiences and attitudes related to open psychotherapy notes using focus groups and telephone interviews. Twenty-four of 29 eligible therapists agreed to open their notes to patients, and nine participated in this study. Participants were generally positive about their experiences and reported few disruptions to their workload or practice. However, they were hesitant to bring up notes to patients during sessions, and they discussed the benefits of open therapy notes mostly hypothetically. The five therapists who did not share notes worried that open notes would be detrimental to therapeutic relationships, patient well-being, and workflow. However, the concern they discussed most often related to the electronic health record rather than to open notes, because therapy notes are visible to all authorized clinicians as part of the general medical record. Future research is needed to deepen our understanding of the risks and benefits of open psychotherapy notes and to inform development of training programs to support therapists in opening notes.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

BACKGROUND: Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks. METHODS: Employing grounded theory, we conducted 86 semi-structured qualitative interviews with experienced ED providers (45 physicians and 41 nurses) from four academic medical centres and four community hospitals in the Northeastern USA. Constant comparative analysis was used to develop a grounded model of provider emotions and patient safety in the ED. RESULTS: ED providers reported experiencing a wide range of emotions in response to patient, hospital, and system-level factors. Patients triggered both positive and negative emotions; hospital and system-level factors largely triggered negative emotions. Providers expressed awareness of possible adverse effects of negative emotions on clinical decision making, highlighting concerns about patient safety. Providers described strategies they employ to regulate their emotions, including emotional suppression, distraction, and cognitive reappraisal. Many providers believed that these strategies effectively guarded against the risk of emotions negatively influencing their clinical decision making. CONCLUSION: The role of emotions in patient safety is in its early stages and many opportunities exist for researchers, educators, and clinicians to further address this important issue. Our findings highlight the need for future work to (1) determine whether providers' emotion regulation strategies are effective at mitigating patient safety risk, (2) incorporate emotional intelligence training into healthcare education, and (3) shift the cultural norms in medicine to support meaningful discourse around emotions.

Embracing the new age of transparency: mental health patients reading their psychotherapy notes online.

Background: Though patients' access to clinicians' visit notes may improve patient engagement and strengthen patient-clinician relationships, it is unknown whether these benefits extend to mental health settings. Aims: Examine patients' attitudes and experiences reading their psychotherapists' notes online. Methods: Using a mixed methods design, we conducted telephone interviews and an online survey of patients at an academic medical center who had opened ≥1 of their psychotherapy notes online. Eleven patients who had read ≥6 psychotherapy notes participated in semi-structured interviews, and 85 patients completed an online survey (response rate = 24%). Results: Nearly all survey respondents (94%) agreed that having open therapy notes is a good idea, and 87% wanted it to continue. More than half reported therapy notes were "very important" (≥7/10 on 0-10 scale) for feeling in control of their care, trusting their providers and taking care of themselves. Two respondents felt offended, and 7 (11%) felt judged by something they read in a note. Interview data supported survey findings. Conclusions: Our pilot findings indicate that most patients who read open therapy notes find them valuable for understanding and engaging in their mental health care, with minimal adverse effects. Larger studies with diverse patient populations are needed.

OpenNotes After 7 Years: Patient Experiences With Ongoing Access to Their Clinicians' Outpatient Visit Notes.

BACKGROUND: Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. OBJECTIVE: The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. METHODS: A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. RESULTS: Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. CONCLUSIONS: In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

The Importance of Visit Notes on Patient Portals for Engaging Less Educated or Nonwhite Patients: Survey Study.

BACKGROUND: OpenNotes, a national initiative to share clinicians' visit notes with patients, can improve patient engagement, but effects on vulnerable populations are not known very well. OBJECTIVE: Our aim is to examine the importance of visit notes to nonwhite and less educated patients. METHODS: Patients at an urban academic medical center with an active patient portal account and ≥1 available ambulatory visit note over the prior year were surveyed during June 2016 until September 2016. The survey was designed with patients and families and assessed importance of reading notes (scale 0-10) for (1) understanding health conditions, (2) feeling informed about care, (3) understanding the provider's thought process, (4) remembering the plan of care, and (5) making decisions about care. We compared the proportion of patients reporting 9-10 (extremely important) for each item stratified by education level, race/ethnicity, and self-reported health. Principal component analysis and correlation measures supported a summary score for the 5 items (Cronbach alpha=.93). We examined factors associated with rating notes as extremely important to engage in care using logistic regression. RESULTS: Of 24,722 patients, 6913 (27.96%) completed the survey. The majority (6736/6913, 97.44%) read at least one note. Among note readers, 74.0% (727/982) of patients with ≤high school education, 70.7% (130/184) of black patients, and 69.9% (153/219) of Hispanic/Latino patients reported that notes are extremely important to feel informed about their care. The majority of less educated and nonwhite patients reported notes as extremely important to remember the care plan (62.4%, 613/982 ≤high school education; 62.0%, 114/184 black patients; and 61.6%, 135/219 Hispanic/Latino patients) and to make care decisions (62.3%, 612/982; 59.8%, 110/184; and 58.5%, 128/219, respectively, and P<.003 for all comparisons to more educated and white patients, respectively). Among patients with the poorest self-reported health, 65.9% (499/757) found notes extremely important to be informed and to understand the provider. On multivariable modeling, less educated patients were nearly three times as likely to report notes were extremely important to engage in care compared with the most educated patients (odds ratio [OR] 2.9, 95% CI 2.4-3.3). Nonwhite patients were twice as likely to report the same compared with white patients (OR 2.0, 95% CI 1.5-2.7 [black] and OR 2.2, 95% CI 1.6-2.9 [Hispanic/Latino and Asian], P<.001 for each comparison). Healthier patients, women, older patients, and those who read more notes were more likely to find notes extremely important to engage in care. CONCLUSIONS: Less educated and nonwhite patients using the portal each assigned higher importance to reading notes for several health behaviors than highly educated and white patients, and may find transparent notes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who have historically been more challenging to reach.

Empowering Informal Caregivers with Health Information: OpenNotes as a Safety Strategy.

BACKGROUND: Enabling family/friend caregivers with access to visit notes may help avoid errors, delayed diagnoses, or other ambulatory safety risks. Patient, parent, and caregiver perceptions of how shared notes affect safety behaviors and attitudes were studied in an exploratory study. METHODS: To assess the impact of OpenNotes on safety, 24,722 patients with active portal accounts and ≥ 1 available visit notes during the prior year at an urban hospital were surveyed between June and September 2016. Surveys were sent to patient portal accounts, and respondents designated themselves as patients or caregivers. Although the hospital does not have formal proxy portal registration, some patients share access with their caregivers. RESULTS: Of 24,722 portal accounts accessed during the study, 7,058 (28.5%) surveys were returned, with 150 (2.1%) participants identified as caregivers. Among patients who had tests and referrals, reading notes helped caregivers understand the reason for the test (96/120 [80.0%]) or referral (48/52 [92.3%]), remember to get patient tests done (66/120 [55.0%]), check (98/120 [81.7%]) and understand (98/120 [81.7%]) results, and remember patient appointments (36/52 [69.2%]). As a result of reading notes, 54.1% (59/109) of caregivers helping patients on prescription medications reported better assisting patients to take them correctly. Among note-reading caregivers, 53.7% (n = 72/134) trusted the clinician more (44.8% no change), and 58.2% (n = 78/134) reported better teamwork (41.0% no change) as a result of open notes. In total, 30.3% (n = 40/132) reported at least one mistake or possible mistake in the patient's notes. Finding a possible mistake did not negatively affect trust or teamwork. CONCLUSION: OpenNotes may enable caregivers with patient health information, answering the call to better support this critical group in the health care system and to engage patients and families in safety efforts.