Connecting Nursing Students and Older Adults: An Intergenerational Service-Learning Experience.

BACKGROUND: Aging populations have an increased need for health care services. Nursing students are often introduced to care of older adults through a clinical experience in a skilled nursing facility, which can negatively bias a student's attitudes toward this population. PURPOSE: The purpose of this quality improvement project was to improve the attitudes of undergraduate nursing students toward older adults. METHOD: Students (N = 104) completed a minimum of 5 visits with an independent community-dwelling older adult. Student attitudes toward older adults were measured before and after the experience using the Polizzi Refined Aging Semantic Differential Scale. Student and older adult participants responded to satisfaction surveys. RESULTS: Statistical and clinically significant improvements in student attitudes were noted after the service-learning intervention. CONCLUSIONS: Nurse educators can impact the way nursing students view the older adult population by including intergenerational service-learning experiences in the curriculum.

The Support, Education, and Advocacy (SEA) Program of Care for Women With Metastatic Breast Cancer: A Nurse-Led Palliative Care Demonstration Program.

BACKGROUND: Women with metastatic breast cancer (MBC) experience unique symptom management and psychosocial needs due to aggressive, yet palliative treatment with a progressive, chronic illness. OBJECTIVE: This article describes the effect of a quality improvement project for coordination of supportive care in MBC. Program evaluations included referral rates for supportive services, patient-reported outcomes of symptom distress, generalized anxiety, and overall well-being. DESIGN: An interdisciplinary Support, Education and Advocacy Program (MBC-SEA) was developed. The 1-hour, weekly, patient review included collaborative assessments to determine needs for social service, psychological counseling, and palliative care. A prospective pre- and postexperimental cohort design with convenience sampling was used. Analysis was conducted with paired t test analysis of pre- and postimplementation outcomes. SETTING/PARTICIPANTS: Program outcomes of 118 women with MBC visiting an urban outpatient breast cancer clinic during September 2016 to November 2016 (pre) and January 2017 to March 2017 (post) were evaluated. MEASUREMENTS: Referral rates to social work and palliative care, symptom, anxiety, and overall well-being scores. RESULTS: Following program implementation, referrals to palliative care and social work supportive services increased significantly including patient-reported outcomes symptom distress scores mean difference 1.4 (95% confidence interval [CI]: 0.4306-2.6428), P = .004; generalized anxiety scores mean difference 1.5 (95% CI: 0.5406-2.5781), P = .003; and overall well-being mean difference of -0.7 (95% CI: -1.3498 to -0.0570), P = .03. CONCLUSIONS: Purposeful nurse-led assessment for social service and palliative care needs increases referrals with improvement in patient-reported outcomes.

Allostasis and the development of internalizing and externalizing problems: changing relations with physiological systems across adolescence.

Allostasis, or the maintenance of stability through physiological change, refers to the process by which individuals adjust to the continually changing demands that are put upon somatic activity by salient events. Bauer and colleagues proposed that allostasis could be detected through patterns of the joint reactivity of the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis system under stressful conditions. We examined the associations between ANS and HPA reactivity and the development of externalizing and internalizing problems over 2 years in a sample of 215 adolescents. The interactions of ANS and HPA reactivity were contemporaneously associated with, and longitudinally predictive of, adolescents' emotional and behavioral problems. Adolescents with symmetrical high reactivity across systems had more internalizing and fewer externalizing problems initially. Over time, both symmetrical and asymmetrical reactivity predicted increasing internalizing problems in girls, depending on the measure of ANS activity that was examined, heart rate, or blood pressure reactivity. Implications for the understanding of allostasis and the dynamic nature of the relations between multiple physiological regulatory systems and adolescents' developing psychopathology are discussed.

Dysregulated coherence of subjective and cardiac emotional activation in adolescents with internalizing and externalizing problems.

BACKGROUND: Effective emotion regulation should be reflected in greater coherence between physiological and subjective aspects of emotional responses. METHOD: Youths with normative to clinical levels of internalizing problems (IP) and externalizing problems (EP) watched emotionally evocative film-clips while having heart rate (HR) recorded, and reported subjective feelings. RESULTS: Hierarchical linear modeling revealed weaker coherence between HR and negative feelings in youths, especially boys, with more EP. Youths with IP showed coherence between HR and negative feelings that did not match the affect portrayed in the eliciting stimuli, but atypical positive emotions: they felt happier when they had slower HR. Youths without problems predominantly showed normative emotional coherence. CONCLUSIONS: Youths with EP and IP experience atypical patterns of activation across physiological and experiential emotion systems which could undermine emotion regulation in evocative situations.

An exploratory study of spiritual care at the end of life.

PURPOSE: Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members. METHODS: Our study was based on qualitative research using key informant interviews and editing analysis with 12 clinicians and other health care workers nominated as spiritual caregivers by dying patients and their family members. RESULTS: Being present was a predominant theme, marked by physical proximity and intentionality, or the deliberate ideation and purposeful action of providing care that went beyond medical treatment. Opening eyes was the process by which caregivers became aware of their patient's life course and the individualized experience of their patient's current illness. Participants also described another course of action, which we termed cocreating, that was a mutual and fluid activity between patients, family members, and caregivers. Cocreating began with an affirmation of the patient's life experience and led to the generation of a wholistic care plan that focused on maintaining the patient's humanity and dignity. Time was both a facilitator and inhibitor of effective spiritual care. CONCLUSIONS: Clinicians and other health care workers consider spiritual care at the end of life as a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.

Providers and types of spiritual care during serious illness.

OBJECTIVE: Patients and palliative care experts endorse the importance of spiritual care for seriously ill patients and their families. However, little is known about spiritual care during serious illness, and whether it satisfies patients' and families' needs. The objective of this study was to describe spiritual care received by patients and families during serious illness, and test whether the provider and the type of care is associated with satisfaction with care. METHODS: Cross-sectional interview with 38 seriously ill patients and 65 family caregivers about spiritual care experiences. RESULTS: The 103 spiritual care recipients identified 237 spiritual care providers; 95 (41%) were family or friends, 38 (17%) were clergy, and 66 (29%) were health care providers. Two-thirds of spiritual care providers shared the recipient's faith tradition. Recipients identified 21 different types of spiritual care activities. The most common activity was help coping with illness (87%) and the least common intercessory prayer (4%). Half of recipients were very or somewhat satisfied with spiritual care, and half found it very helpful for facilitating inner peace and meaning making. Satisfaction with spiritual care did not differ by provider age, race, gender, role, or frequency of visits. Types of care that helped with understanding or illness coping were associated with greater satisfaction with care. CONCLUSION: Seriously ill patients and family caregivers experience spiritual care from multiple sources, including health care providers. Satisfaction with this care domain is modest, but approaches that help with understanding and with coping are associated with greater satisfaction.

Clinical and economic impact of palliative care consultation.

Palliative care consultation is the most common model of hospital-based services in the United States, but few studies examine the impact of this model. In a prospective study, we describe the impact of palliative care consultation on symptoms, treatment, and hospital costs. Patients receiving interdisciplinary palliative care consultations from 2002 to 2004 were approached for enrollment; 304 of 395 (77%) patients participated. Measures included diagnosis, treatment decisions, and symptom scores. To test impact on costs, a one-year subset of cases with lengths of stay >4 days (n=104) was compared to all available controls (n=1,813) matched on the 3Mtrade mark All Patients Refined Diagnosis Related Group, Version 20, and mortality risk scores. Half of the patients were younger than 65 years, 28% were African American, and 61% had cancer. Median Palliative Performance score was 20 (range, 10-100). Recommendations were implemented in 88% of cases; new "do not resuscitate/do not intubate" orders were written for 34% of patients, new comfort care orders for 44%, and 27% were referred for hospice care. Symptom scores improved from Day 1 to Day 3, with greatest improvement in pain (2.6-1.4, P<0.001). Compared to matched controls without palliative care consultation, palliative care cases had lower cost per day ($897 vs. $1004, P=0.03). Per diem variable costs were 10.7% less for all palliative care cases and 20.5% less for those with >50% hospital days with palliative care consultation. Palliative care consultation is followed by decisions to forego costly treatment and improved symptom scores, and earlier palliative care intervention results in greater cost-savings.

Young children's representations of conflict and distress: a longitudinal study of boys and girls with disruptive behavior problems.

We investigated narratives, symbolic play, and emotions in children who varied in severity of disruptive behavior problems. Children's representations of hypothetical situations of conflict and distress were assessed at 4-5 and 7 years. Behavior problems also were assessed then and again at 9 years. Children's aggressive and caring themes differentiated nonproblem children, children whose problems remained or worsened with age, and those whose problems improved over time. Differences in boys and girls whose problems continued sometimes reflected exaggerations of prototypic gender differences seen across the groups. Boys with problems showed more hostile themes (physical aggression and anger), whereas girls with problems showed more caring (prosocial) themes relative to the other groups. Modulated (verbal) aggression, more common in girls than boys, showed developmentally appropriate increases with age. However, this was true only for children without problems and those whose problems improved. We consider how these findings contribute to an understanding the inner worlds of boys and girls who differ in their early developmental trajectories for behavior problems.

Palliative care benchmarks from academic medical centers.

INTRODUCTION: Palliative care is growing in the United States but little is known about the quality of care delivered. OBJECTIVE: To benchmark the quality of palliative care in academic hospitals. DESIGN: Multicenter, cross-sectional, retrospective chart review conducted between October 1, 2002 and September 30, 2003. SETTING: Thirty-five University HealthSystem Consortium (UHC) academic hospitals across the United States. PARTICIPANTS: A total of 1596 patient records. INCLUSION CRITERIA: (1) adults, (2) high-mortality diagnoses: selected cancers, heart failure, human immunodeficiency virus (HIV), and respiratory conditions requiring ventilator support, (3) length of stay (LOS) more than 4 days, and (4) two prior admissions in the preceding 12 months. MAIN OUTCOME MEASURES: Compliance with 11 key performance measures (KPM) derived from practice standards, literature evidence, and input from a multidisciplinary expert committee. Analyses examined relationships between provision of the KPM and specific outcomes. RESULTS: Wide variability exists among academic hospitals in the provision of the KPM (0%-100%). The greater the compliance with KPM, the greater the improvement in quality outcomes, cost and LOS. Assessment of pain (96.1%) and dyspnea (90.2%) was high, but reduction of these symptoms was lower (73.3% and 77.2%). Documentation of prognosis (33.4%), psychosocial assessment (26.2%), communication with family/patient (46%), and timely planning for discharge disposition (53.4%) were low for this severely ill population (16.8% hospital mortality). Only 12.9% received a palliative care consultation. CONCLUSIONS: The study reveals significant opportunities for improvement in the effective delivery of palliative care. Care that met KPM was associated with improved quality, reduced costs and LOS. Institutions that benchmarked above 90% did so by integrating KPM into daily care processes and utilizing systematized triggers, forms and default pathways. The presence of a formalized palliative care program within a hospital system had a positive effect on the achievement of KPM, whether or not formal consultation occurred. Hospitals need to develop systematic methods to improve access to palliative care.

Validation of the palliative performance scale in the acute tertiary care hospital setting.

BACKGROUND: Physicians are often asked to prognosticate patient survival. However, prediction of survival is difficult, particularly with critically ill and dying patients within the hospitals. The Palliative Performance Scale (PPS) was designed to assess functional status and measure progressive decline in palliative care patients, yet it has not been validated within hospital health care settings. OBJECTIVE: This study explores the application of the PPS for its predictive ability related to length of survival. Other variables examined were correlates of symptom distress in a tertiary academic setting. METHODS: Patients were assigned a score on the PPS ranging from 0% to 100% at initial consultation. Standardized symptom assessments were carried out daily, and survival was determined by medical record review and search of the National Death Index. RESULTS: Of 261 patients seen since January 2002, 157 had cancer and 104 had other diagnoses. PPS scores ranged from 10% to 80% with 92% of the scores between 10% and 40%. Survival ranged from 0 to 30 months, with a median of 9 days. By 90 days, 83% of patients had died. Proportional hazards regression estimates showed that a 10% decrement in PPS score was associated with a hazard ratio of 1.65 (95% confidence interval [CI]: 1.42-1.92). Proportional odds regression models showed that a lower PPS was significantly associated with higher levels of dyspnea. CONCLUSION: The PPS correlated well with length of survival and with select symptom distress scores. We consider it to be a useful tool in predicting outcomes for palliative care patients.

Salivary testosterone diurnal variation and psychopathology in adolescent males and females: individual differences and developmental effects.

Individual differences in salivary testosterone were examined in 213 adolescents (106 boys, 107 girls; mean age = 13.66 years) in relation to externalizing and internalizing psychopathology. Self- and parent-report measures of behavior problems and psychiatric symptoms were obtained. Latent anxiety-depression, disruptive behavior, and attention problem constructs were developed using multitrait, multimethod procedures. Saliva samples were collected in the morning, midday, and late afternoon on multiple days and were later assayed for testosterone. Latent constructs were derived for testosterone level and diurnal variation across the six sampling occasions. Structural equations modeled relationships between problem behavior and intra- and interindividual differences in testosterone separately by gender. For boys, lower levels of testosterone and testosterone levels that decreased more slowly across the day were related to higher levels of anxiety-depression and attention problems. These associations were not moderated by pubertal development. For girls, steep declines in testosterone production across the day related to higher levels of disruptive behavior problems, but this association was only evident after including pubertal development as a moderator in the model. These findings raise novel questions regarding the nature and magnitude of links between testosterone and problem behavior in youth.

The development of concern for others in children with behavior problems.

The development of concern for others and externalizing problems were examined in young children with normative, subclinical, or clinical levels of behavior problems. There were no group differences in observable concern for others at 4-5 years of age. Children with clinical behavior problems decreased significantly in their concern by 6-7 years of age and were reported to have less concern at 6-7 years by mothers, teachers, and the children themselves, relative to other groups. Boys with clinical problems were more callous to others' distress at both time points. Girls showed more concern than boys across risk, time, and measures. Greater concern at 4-5 years predicted decreases in the stability and severity of externalizing problems by 6-7 years, and greater concern at 6-7 years predicted decreases in the stability of problems by 9-10 years. Finally, maternal socialization approaches predicted later concerned responding.