Using Simulation-Based Learning with Standardized Patients (SP) in an Implicit Bias Mitigation Clinician Training Program.

Objectives: To describe the development and refinement of an implicit bias recognition and management training program for clinical trainees. Methods: In the context of an NIH-funded clinical trial to address healthcare disparities in hypertension management, research and education faculty at an academic medical center used a participatory action research approach to engage local community members to develop and refine a "knowledge, awareness, and skill-building" bias recognition and mitigation program. The program targeted medical residents and Doctor of Nursing Practice students. The content of the two-session training included: didactics about healthcare disparities, racism and implicit bias; implicit association test (IAT) administration to raise awareness of personal implicit bias; skill building for bias-mitigating communication; and case scenarios for skill practice in simulation-based encounters with standardized patients (SPs) from the local community. Results: The initial trial year enrolled n = 65 interprofessional participants. Community partners and SPs who engaged throughout the design and implementation process reported overall positive experiences, but SPs expressed need for greater faculty support during in-person debriefings following simulation encounters to balance power dynamics. Initial year trainee participants reported discomfort with intensive sequencing of in-person didactics, IATs, and SP simulations in each of the two training sessions. In response, authors refined the training program to separate didactic sessions from IAT administration and SP simulations, and to increase safe space, and trainee and SP empowerment. The final program includes more interactive discussions focused on identity, race and ethnicity, and strategies to address local health system challenges related to structural racism. Conclusion: It is possible to develop and implement a bias awareness and mitigation skills training program that uses simulation-based learning with SPs, and to engage with local community members to tailor the content to address the experience of local patient populations. Further research is needed to measure the success and impact of replicating this approach elsewhere.

Facilitating diversity of thought in learning environments for nursing students.

Human capital development is one of the goals of higher education and a decrease in open dialogue threatens these ideals and aspirations. A recent survey of undergraduate students showed that many students censor their point of view. There are many potential reasons for this, but it could be secondary to the current sociopolitical climate. Having educators who encourage and model open dialogue while supporting diversity of thought would provide alternative perspectives and innovation. Encouraging diversity of thought will enhance understanding of other's perspectives and unleash creative problem solving to address concerns in nursing practice and facilitate innovative research. The purpose of this article is to present strategies that can be employed to promote diversity of thought among nursing students in a learning environment. Exemplars are presented illustrating some of the strategies discussed.

E-Cigarettes-a review of the evidence-harm versus harm reduction.

The World Health Organization estimates there are 1.1 billion cigarette smokers across the globe and that tobacco related deaths number 7 million per year. Electronic nicotine delivery systems (ENDS) are available to contribute options for smoking cessation and include e-cigarettes, e-hookahs, vape pens, mods, and vaping. The growing use of ENDS, or e-cigarettes, in the US and globally across populations is dramatic. Although users may think that e-cigarettes are less harmful than combustible tobacco products, the evidence shows that there are known risks and harms for users. E-cigarettes have varying amounts of toxicants, nicotine, and carcinogens and put the user at risk for lung diseases and COVID-19 similar to smokers. Currently, most governing bodies have not approved e-cigarettes as a smoking cessation tool but do state if a person has failed conventional smoking cessation treatments that e-cigarettes used alone for the short term may help those to quit combustible tobacco and nicotine. A shared decision-making approach should be used when discussing e-cigarettes as a harm reduction tool. More studies and long-term data are needed to assess potential benefits and harms. What is known is that prevention efforts and policy are needed to avoid adolescents and other vulnerable populations from initiating tobacco or e-cigarette use.

COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol.

BACKGROUND: Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness. METHODS: We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare. DISCUSSION: Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes. TRIAL REGISTRATION: NCT03375918. PROTOCOL VERSION: 1.0 (November 10, 2020).

E-Cigarettes: Background and Essential Information for Providers.

E-cigarettes are rapidly increasing in use across all populations, particularly in adolescents and young adults. Smoking cessation is important for patients with cancer; however, evidence supporting e-cigarettes as an effective cessation strategy is lacking and not currently recommended. Information on risks, safety, and recommendations regarding vaping will be discussed. Oncology nursing considerations for e-cigarettes include communicating known and potential risks while using smoking cessation strategies for people at risk for cancer or who have cancer and are currently vaping.

Integration of primary care into the substance use disorder outpatient treatment setting.

BACKGROUND: Americans experiencing substance use disorder (SUD) carry a significant chronic disease burden, yet only half use primary care. Patients in treatment for SUD who are connected with primary care typically have better overall health outcomes. LOCAL PROBLEM: The identified intensive outpatient program (IOP) had no protocol in place to engage patients with primary care. METHODS: This project piloted the development and implementation of an original, evidence-based primary care integration program. It consisted of a psychoeducation group, a referral by case management, and establishment of an internal referral process to affiliated primary care providers (PCPs). INTERVENTIONS: Following the psychoeducation group, pre and posttests of patient-reported knowledge and attitudes regarding primary care were compared. Participants were contacted to collect further data after IOP discharge. An education and feedback session was held with affiliated PCPs, and an internal referral process was devised by leadership. RESULTS: Mean scores measuring patient knowledge and attitudes regarding primary care increased after participation in the structured psychoeducation group. By time of IOP discharge, 100% (n = 12) of participants had either a referral or scheduled appointment with a PCP in place. At time of follow-up, 90% (n = 9) reported that they had attended or planned to attend their scheduled PCP appointment. CONCLUSIONS: A comprehensive integration program in the IOP setting can improve patient engagement with primary care. Quality improvement implementation will require consideration of challenges faced during the pilot involving scheduling, staff buy-in, changes in patient acuity, the electronic medical record, and insurance.

The impact of deliberate reflection with WISE-MD™ modules on surgical clerkship students' critical thinking: a prospective, randomized controlled pilot study.

PURPOSE: Critical thinking underlies several Association of American Medical Colleges (AAMC)-defined core entrustable professional activities (EPAs). Critical-thinking ability affects health care quality and safety. Tested tools to teach, assess, improve, and nurture good critical-thinking skills are needed. This prospective randomized controlled pilot study evaluated the addition of deliberate reflection (DR), guidance with Web Initiative in Surgical Education (WISE-MD™) modules, to promote surgical clerks' critical-thinking ability. The goal was to promote the application of reflective awareness principles to enhance learning outcomes and critical thinking about the module content. PARTICIPANTS AND METHODS: Surgical clerkship (SC) students were recruited from two different blocks and randomly assigned to a control or intervention group. The intervention group was asked to record responses using a DR guide as they viewed two selected WISE-MD™ modules while the control group was asked to view two modules recording free thought. We hypothesized that the intervention group would show a significantly greater pre- to postintervention increase in critical-thinking ability than students in the control group. RESULTS: Neither group showed a difference in pre- and posttest free-thought critical-thinking outcomes; however, the intervention group verbalized more thoughtful clinical reasoning during the intervention. CONCLUSION: Despite an unsupported hypothesis, this study provides a forum for discussion in medical education. It took a sponsored tool in surgical education (WISE-MD™) and posed the toughest evaluation criteria of an educational intervention; does it affect the way we think? and not just what we learn, but how we learn it? The answer is significant and will require more resources before we arrive at a definitive answer.

A pilot study to explore next of kin's perspectives on end-of-life care in the nursing home.

OBJECTIVES: To explore next-of-kin's (NOK's) perceptions of end-of-life (EOL) care in the nursing home setting and to compare these perceptions for residents receiving hospice care plus usual care versus usual care only. DESIGN: Mailed survey. SETTING: Three nursing homes in central Massachusetts. PARTICIPANTS: Nursing home decedents' NOK MEASUREMENTS: Nursing home decedents' NOK were identified from nursing home records. Survey data were collected on NOK demographics and perceptions of decedents' EOL care. This care included nursing home care and services received by decedents, pain and symptom management, communication about decedents' care, and advance directives. RESULTS: Of 164 surveys mailed, 114 surveys were returned (70% response rate) with 100 completed (61% used for analysis). NOK reported that nursing home decedents had a high symptom burden, with at least 70% experiencing pain, agitation, and/or anxiety, and 60% having shortness of breath or depression. Most NOK reported good-to-excellent symptom control for decedents (88%), feeling well informed about the decedent's condition (91%), satisfaction with medical and nursing care (90%), and the decedent having advance directives in place (89%). Respondents' impressions of decedents' symptom control, communication about decedents' care, level of care, or advance directives did not differ significantly between the hospice plus usual care and usual care only groups. CONCLUSION: In this pilot study, NOK perceived that decedents' EOL care in the nursing home was of similarly good quality under hospice care plus usual care and usual care only. Our study provides an approach to assessing quality of EOL care in the nursing home setting.