The COVID-19 Crucible: 2 Lived Experiences at the Epicenter.

This article describes how a national nursing association and a major academic medical center responded to the coronavirus disease-2019 (COVID-19) pandemic during the first wave of the outbreak in the United States (January to August 2020). The organizations share their lived experiences as they quickly found themselves at the forefront of the crisis. The article discusses how early warning signs from a world away sparked collaboration, innovation, and action that grew to a coordinated, organization-wide response. It also explores how leaders in 2 distinct but interrelated environments rose to the challenge to leverage the best their organizations had to offer, relying on the expertise of each to navigate changes that were made to almost every aspect of work. From tentative first steps to rapid implementation of innovative policies and procedures, the organizations share lessons learned and benefits reaped. The article includes practical crisis response strategies for the nursing profession and health care systems moving forward.

Differentiating research and quality improvement activities: A scoping review and implications for clinical scholarship.

BACKGROUND: Differentiating activities that are research or quality improvement (QI) is challenging. PURPOSE: Compare tools that distinguish research from QI and evaluate the utility of tools to determine whether institutional review board (IRB) approval is required for a test-project. METHODS: Scoping review of the literature to identify tools that distinguish QI from research. Two reviewers independently screened records in PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Google Scholar and extracted information from tools. Inclusion criteria were English language peer-reviewed publications or publicly available tools with scoring systems to differentiate between research and QI. The reporting of this review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We then applied a test-project to evaluate the utility of the tools. FINDINGS: One-hundred forty sources were reviewed; 13 met inclusion criteria. Tools consistently used project intent/purpose, design and intervention as differentiating criteria; additional criteria varied. Five studies described tool development, and one reported that the tool had been tested. Our application of a test-project proved challenging as tools commonly presented research and QI as discrete activities. DISCUSSION: Based on the core criteria common across tools to distinguish research from QI, we propose a simple four-criteria decision tool for assessing the need for IRB submission.

Prevalence, Incidence, and Factors Associated with Posttraumatic Stress at Three-Month Follow-Up among New York City Healthcare Workers after the First Wave of the COVID-19 Pandemic.

BACKGROUND: Prevalence, incidence, and factors associated with posttraumatic stress disorder (PTSD) symptoms at follow-up among healthcare workers after the first wave of the COVID-19 pandemic are unknown. METHODS: A web survey invitation was sent to healthcare worker listservs at a NYC medical center (April, 2020). The Primary Care (PC)-PTSD questionnaire was used to screen for PTSD symptoms at baseline and then every 2 weeks for 10 weeks. Incidence and prevalence of PTSD symptoms were determined at each time point. Multivariable generalized estimating equation models were performed to investigate the factors associated with a positive PC-PTSD screen at follow-up. RESULTS: Median age (interquartile range) of N = 230 participants was 36 (31-48) years; 79.6% were women; 82.6% worked in COVID-19-focused settings. The prevalence of PTSD symptoms decreased from 55.2% at baseline to 25.0% at 10 weeks (p < 0.001). Among participants who had a baseline negative screen for PTSD symptoms, the incidence of PTSD at 10 weeks was 12.2% (p-trend 0.034). In multivariable-adjusted analyses, being a nurse (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.06-2.71), female (OR: 3.00, 95% CI: 1.59, 5.72), and working in a COVID-19-focused location (OR: 1.51, 95% CI: 1.02, 2.21) were associated with increased odds of PTSD symptoms at 10-weeks. CONCLUSIONS: PTSD symptoms improved over 3 months following the first wave of the COVID-19 pandemic. However, one out of four NYC healthcare workers still had an increased risk for PTSD at 10-weeks. Screening healthcare workers for PTSD symptoms should be considered during the COVID-19 pandemic.

Programmatic details and outcomes of an Academic-Practice Research Fellowship for clinical nurses.

AIM: Describe the programmatic details and outcomes of a competitive, two-year Academic-Practice Research Fellowship for clinical nurses. BACKGROUND: Numerous barriers challenge clinical nurses in their ability to conduct and disseminate research. We describe and evaluate a competitive, semi-structured, two-year Academic-Practice Research Fellowship in which clinical nurse 'fellows' accepted into the program are paired with a faculty mentor at a school of nursing to conduct and disseminate a research study that addresses a clinical problem identified by the fellow. The fellowship is facilitated by the Director of Academic-Practice Partnerships jointly appointed between a school of nursing and affiliated acute care hospitals, and with resources provided by both. The vast majority of didactic training is provided outside the classroom. METHODS: We reviewed administrative records to describe the programmatic details and outcomes of the program. RESULTS: Thirteen nurses were accepted into the first three cohorts of the Academic-Practice Research Fellowship. Among the five fellows in the graduating first cohort, all successfully completed their research, presented their findings at national or international conference(s) and four have submitted manuscripts for publication, with two being accepted for publication. The eight current fellows are meeting all delineated milestones and timelines. Evaluations demonstrate the effectiveness of the fellowship in enhancing the professional development and research capacity of clinical nurses. CONCLUSIONS: The Academic-Practice Research Fellowship program integrates expertise and resources across academia and practice and has resulted in the successful conduct and dissemination of clinically relevant research by fulltime practicing nurses in the acute care setting.

Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic.

OBJECTIVE: The mental health toll of COVID-19 on healthcare workers (HCW) is not yet fully described. We characterized distress, coping, and preferences for support among NYC HCWs during the COVID-19 pandemic. METHODS: This was a cross-sectional web survey of physicians, advanced practice providers, residents/fellows, and nurses, conducted during a peak of inpatient admissions for COVID-19 in NYC (April 9th-April 24th 2020) at a large medical center in NYC (n = 657). RESULTS: Positive screens for psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms. For each, a higher percent of nurses/advanced practice providers screened positive vs. attending physicians, though housestaff's rates for acute stress and depression did not differ from either. Sixty-one percent of participants reported increased sense of meaning/purpose since the COVID-19 outbreak. Physical activity/exercise was the most common coping behavior (59%), and access to an individual therapist with online self-guided counseling (33%) garnered the most interest. CONCLUSIONS: NYC HCWs, especially nurses and advanced practice providers, are experiencing COVID-19-related psychological distress. Participants reported using empirically-supported coping behaviors, and endorsed indicators of resilience, but they also reported interest in additional wellness resources. Programs developed to mitigate stress among HCWs during the COVID-19 pandemic should integrate HCW preferences.

Music Therapy and Pain Management in Patients with End-Stage Liver Disease: An Evidence-Based Practice Quality Improvement Project.

BACKGROUND: Pain can negatively affect the inpatient hospitalization experience; however, in patients with compromised metabolic pathways who are more vulnerable to medication side effects, pain control becomes even more challenging. AIMS: This evidence-based practice quality improvement project explored the feasibility of implementing a music therapy intervention for improved pain management (pain intensity, analgesic volume) and patient satisfaction among patients with a diagnosis of cirrhotic end-stage liver disease in the acute care setting. DESIGN: The plan-do-check-act cycle served as the implementation framework. Four nurse champions were trained to implement a 30-minute music intervention. Self-selected musical selections were delivered via unit-based iPads with earbud headphones during 3 consecutive days. METHODS: Data collection was performed using unit-based measures for pain and patient satisfaction and an investigator-developed audit tool. Bivariate analyses and descriptive statistics were used to assess the effect of the intervention on the three outcomes of interest. RESULTS: Overall results from data collected with eight participants during a 6-week period indicated a 10% reduction in pain intensity and a 30% improvement in patient satisfaction with pain management care. CONCLUSIONS: Findings from this evidence-based practice quality improvement project provide support for the effectiveness of music therapy as an adjunct to traditional pharmacologic modalities for pain management of the end-stage liver disease patient population.

Clarifying the Conundrum: Evidence-Based Practice, Quality Improvement, or Research?: The Clinical Scholarship Continuum.

Nurses' active involvement in clinical scholarship is necessary to advance the nursing profession and improve patient outcomes. Yet, definitional confusion and numerous barriers exist to clinical scholarship in and across academic and patient care settings. We discuss factors that pose barriers to the continuum of clinical scholarship and suggest opportunities for clinician-researcher collaborations that promote nurses' engagement in evidence-based practice, quality improvement, and research.

Using LEAN to improve a segment of emergency department flow.

Emergency department (ED) overcrowding is an organizational concern. This article describes how Toyota LEAN methods were used as a performance improvement framework to address ED overcrowding. This initiative also impacted "bolus of patients" or "batching" concerns, which occur when inpatient units receive an influx of patients from EDs and other areas at the same time. In addition to decreased incidence of overcrowding, the organization realized increased interprofessional collaboration.

Establishing a comprehensive networkwide pressure ulcer identification process.

BACKGROUND: Pressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented. IMPLEMENTATION: An interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff. RESULTS: The total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources. CONCLUSIONS: The data suggest that the identification of all PUs that are present at time of admission is clinically feasible.

Research on the frontlines of healthcare: a cooperative learning approach.

BACKGROUND: Evidence-based practice is a common goal in hospitals, but learning about research so that the practice can be done is often challenging for clinicians. OBJECTIVES: The aims of this study were to (a) develop a process that supports organizational and staff development while conducting research and (b) conduct a research study in the emergency department (ED) to examine patient population, satisfaction, and waiting room issues. METHODS: A multidisciplinary team of clinicians and scientists was assembled to learn and do research while evaluating the ED waiting room of a Level I trauma center. A cooperative learning method approach was used to teach research concepts as the study was designed and implemented. RESULTS: The team demonstrated their knowledge and understanding of research concepts by being involved actively in the creation and implementation of the preintervention study. Using information from photographs, observations, and a questionnaire, the team identified the following key dissatisfaction areas: (a) atmosphere (including comfort with environment, neatness and cleanliness, and noise), (b) telephones, (c) parking and thoroughfare, (d) professional behavior and staff presence (including personal attention), (e) security, and (f) triage and confidentiality. DISCUSSION: The model of working in partnership with researchers and using cooperative, collaborative research is an effective way to evaluate and address issues related to quality of care while learning about the research concepts needed to put evidence into practice.