Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting.

PURPOSE: The purpose of this study was to determine whether an adaptation of the Diabetes Prevention Program (DPP) could be successfully implemented in a correctional environment to promote weight loss, lower A1C, and improve other cardiometabolic outcomes. METHODS: A quasi-experimental, staggered-start control study was conducted in a female and male federal correctional institution. Twenty-six male and 21 female incarcerated, overweight individuals with prediabetes or at high risk for developing diabetes were randomly assigned to two groups. Data were measured at 6-month intervals starting at baseline for 18 months. Group 1 participated in the 12-month Group Lifestyle Balance intervention program from baseline to 12 months. Group 2 served as a control group from baseline for 6 months and then completed the intervention program from months 6 to 18. RESULTS: Participants were ethnically diverse and mostly >44 years of age. At baseline, members of the two study groups were not significantly different with regard to sex, race/ethnicity, age, or prediabetes status. About half of participants (51%) completed the program, with participants in group 1 significantly more likely to be completers (P <0.05). At 6 months, participants in the intervention group had significantly more weight loss on average (12 lb) than those in the control/delayed-start group (5 lb) (P <0.001). However, both groups (active intervention and control) experienced significant decreases in weight, BMI, triglycerides, and A1C levels after 6 months. In combined analysis, after the 12-month intervention, participants in both groups demonstrated significant decreases in BMI (P <0.001) and A1C (P <0.001) from baseline. CONCLUSION: The DPP may be an effective method for reducing the impact of diabetes in the correctional environment addressed. Larger studies should be conducted to confirm these outcomes. Study findings were affected by high attrition rates, primarily due to transfers and releases from the institution.

A culture of avoidance: voices from inside ethically difficult clinical situations.

BACKGROUND: Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families. OBJECTIVES: The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice. METHODS: The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators. FINDINGS: The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

The nature of ethical conflicts and the meaning of moral community in oncology practice.

PURPOSE/OBJECTIVES: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH: Ethnography. SETTING: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

Making the call: a proactive ethics framework.

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly--often with lingering effects such as healthcare providers' disengagement and moral distress (McAndrew et al. Journal of Trauma Nursing 18(4):221-230, 2011), compromised inter-professional relationships (Rosenstein and O'Daniel American Journal of Nursing, 105(1):54-64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1-11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486-490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results.