Nursing Students' Perception of Caring for Culturally Diverse Patients: A Hermeneutic Phenomenological Study.

BACKGROUND: This study examined the phenomenon of prelicensure nursing students caring for culturally diverse patients. METHOD: Individual interviews were conducted with undergraduate nursing students using a hermeneutic phenomenological approach. Qualitative research experts conducted the interviews, transcribed the data, and followed van Manen's methodology for analysis. RESULTS: Eleven nursing students participated in the study. Data were collected from April to August 2022. The average length of the student interviews was 32 minutes. Four themes were identified: (1) communication issues; (2) access to care; (3) nurse background; and (4) trust and respect. CONCLUSION: This study highlights the importance of caring for culturally diverse patients. Policymakers and health care leaders can use the findings to support legislative proposals for enhancing culturally diverse patient safety and health equity. Based on these findings, nurse educators and preceptors can adapt their clinical teaching approaches accordingly, and nurse managers can benefit from the results when hiring new graduate nurses. [J Nurs Educ. 2024;63(6):373-379.].

Understanding primary palliative nursing education in undergraduate nursing programs.

BACKGROUND: Nurses are the largest segment of health care professionals and often the first one to interact with individuals about their health and illness. Ensuring nurses have the education to care for individuals with serious illness is essential to quality health care. The new AACN Essentials: Competencies for Professional Nursing Education delineates hospice/palliative/supportive care as one of four spheres of nursing care. Surveying undergraduate schools/colleges of nursing in Massachusetts about content pertaining to care of individuals with serious illness provides the foundation for a state strategy to ensure quality primary palliative education for undergraduate nursing students. METHODS: A Massachusetts statewide college/school of nursing survey approach to assessing primary palliative nursing education within undergraduate baccalaureate nursing curricula was performed from June 2020 to December 2020. Because the project was a collaboration with the Deans of the college/school of nursing, the survey identified the programs. RESULTS: Survey results revealed that only a small number of Massachusetts nursing programs are preparing nurses with specific and formal primary palliative nursing education. However, programs are open to support and resources. CONCLUSION: The survey provided information to inform a successful strategy to support primary palliative nursing education within Massachusetts undergraduate baccalaureate nursing curricula. A survey approach can serve as a model for other states.

"I liked just that it was a communal thing": Feasibility and acceptability of engaging with transgender and gender-diverse persons in a digital photovoice research study on commercial cigarette smoking risk and protective factors.

Background: Commercial cigarette smoking is the leading modifiable risk factor for more than 16 types of cancer. Over one-third (35.5%) of transgender and gender-diverse (TGD) adults smoke cigarettes compared to 14.9% of cisgender adults. The objective of this paper is to describe the feasibility of enrolling and engaging with TGD persons in a digital photovoice study to examine smoking risk and protective factors through real-world experiences (Project SPRING). Methods: The study comprised a purposeful sample of 47 TGD adults aged ≥18 years who currently smoke and live in the United States (March 2019-April 2020). They participated in three weeks of digital photovoice data collection using Facebook and Instagram closed groups. A subsample participated in focus groups to explore smoking risks and protective factors in greater depth. We summarized the enrollment strategies and accrual rates, participant engagement (posts, comments, and reactions) during the photovoice data collection to assess study feasibility, and respondent feedback on acceptability and likability during and after the study. Results: Participants were recruited via Facebook/Instagram advertising (n = 33) and via Craigslist/word-of-mouth (n = 14). Costs ranged from $29 via Craigslist/word-of-mouth to $68 per recruited participant via Facebook/Instagram advertising. On average, participants posted 17 pictures of smoking risks/protective factors, commented 15 times on others' posts, and had 30 reactions within their group over 21 days. Participants' rating of the acceptability and likability of the study were positive based on closed- and open-ended feedback. Conclusion: The findings of this report will inform future research to engage with TGD community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGD individuals.

Understanding The Use Of Medicare Procedure Codes For Advance Care Planning: A National Qualitative Study.

In 2016 Medicare introduced advance care planning Current Procedural Terminology (CPT) codes to reimburse clinicians for time spent providing the service. Despite recent increases, use of these codes remains low for reasons incompletely captured by quantitative research. To further identify barriers and facilitators to code use for Medicare fee-for-service enrollees, we conducted case studies at eleven health systems, including 272 interviews with clinicians, administrators, and key leadership. Five themes related to use of the new codes emerged: code-based constraints to billing, burdening patients with unexpected charges, ethical concerns with billing for discussion of advance care plans, incentives to signal the importance of their use in billing, and increasing both workflow burden and the need for institutional supports and training. Respondents also observed that use was facilitated by health systems' investment in clinician training and in processes to audit the codes' use. Our findings suggest that increased reimbursement, strong institutional commitment and support, and streamlined workflow could improve the use of the new CPT codes to document receipt of and ensure access to Medicare advance care planning.

"Don't Talk to Them About Goals of Care": Understanding Disparities in Advance Care Planning.

BACKGROUND: Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. METHOD: In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. RESULTS: Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (preconceived views of patients' preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences). CONCLUSIONS: Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.

Smoking Protective and Risk Factors Among Transgender and Gender-Expansive Individuals (Project SPRING): Qualitative Study Using Digital Photovoice.

BACKGROUND: Transgender and gender-expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. There is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among TGE adults. OBJECTIVE: This study aims to qualitatively examine the risk and protective factors of cigarette smoking among TGE adults through real-world exemplars. METHODS: We conducted a digital photovoice study among a purposeful sample of 47 TGE adults aged ≥18 years and currently smoking in the United States (March 2019-April 2020). Participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private Facebook or Instagram groups. Next, we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group. We analyzed participants' photos, captions, and focus group transcripts and generated themes associated with smoking risk and protective factors. RESULTS: We identified 6 major themes of risk and protective factors of smoking among TGE individuals: experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues. We describe and illustrate each theme using exemplar photos and quotes. CONCLUSIONS: The findings of this study will inform future community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGE individuals.

Patients' and Care Partners' Perspectives on Dignity and Respect During Acute Care Hospitalization.

BACKGROUND: Delivering patient-centered care (PCC) is essential to our healthcare system. Patient dignity and respect are foundational elements of PCC. Understanding patients' and their care partner's perspectives on the meaning of dignity and respect within a clinical care environment is critical to achieving our goal of PCC. OBJECTIVE: The aim of the study was to understand how patients and their care partners define, describe, and experience dignity and respect during hospitalization. METHODS: We conducted a qualitative study with 22 patients and care partners hospitalized in high-acuity patient care areas in 1 academic medical center. Data collected from semistructured interviews were analyzed using grounded theory open coding in Atlas Ti software. RESULTS: Our data provide a definition of dignity and respect during hospitalization from the patient and care partner perspective and a conceptual model of the factors needed to enhance patients' and care partners' experience of dignity and respect in the hospital setting. Dignity was felt to be intrinsic to personhood including the recognition of that person's value by others. Respect was characterized as the behavioral or social norms that acknowledge dignity. Determinants of dignity and respect were categorized at the organizational (macro) level and within the microsystem between clinicians, patients, and their care partners. CONCLUSIONS: The definition of dignity and respect and the conceptual model presented here represent an important supplement to our understanding of dignity and respect during hospitalization. Healthcare organizations should focus on the key factors found in this study to create a culture that treats patients with dignity and respect.

Use of Course-Specific Open Educational Resources in a Graduate Nursing Course.

BACKGROUND: This article evaluates a single-institution educational innovation using course-specific open educational resources (OER). METHOD: This educational innovation uses a course-specific library resource guide of OERs and evaluates students' perspectives on the quality, integration, and experience with the resources. At the completion of a nursing graduate course, the OER Satisfaction Scale was administered to the course participants. The course-specific OERs were assessed compared to students' experiences with traditional course materials. RESULTS: The overall score on the OER Satisfaction Scale was 4.01 on a 5-point Likert Scale. Students appreciated that the resources were free and found that the information was manageable and easy to navigate. However, they were challenged with shutting out other distractions and taking useful notes. CONCLUSION: Using OERs enhanced student engagement with the course content by requiring learners to assume a more active role as course participants. Further work is needed to understand the effectiveness of OERs, particularly in graduate nursing education. [J Nurs Educ. 2020;59(10):577-580.].

A systematic evaluation of advance care planning patient educational resources.

BACKGROUND: Advance care planning (ACP) conversations help individuals exercise autonomy and make informed decisions about their care. There are many ACP resources available to support the process of advance care planning, yet available resources not universally accepted and under-utilized in clinical practice. OBJECTIVE: This study aims to systematically evaluate commonly available general ACP patient educational resources using a comprehensive approach to assess elements ranging from resource inclusion to health literacy. DESIGN: Systematic evaluation of general ACP educational resources METHODS: ACP educational resources were systematically identified and evaluated for: Patient Education Materials Assessment Tool (PEMAT) score, Flesch-Kincaid reading ease and grade level, cost, languages available, and categories of content including Advance directive/Healthcare proxy, Physician Order for Life-Sustaining Treatment (POLST), Living will, values, preferences, and goals. RESULTS: Educational resources (n = 20) were identified. These resources were classified as information resources, workbooks, interactive websites, or and activities/conversation guides. The average PEMAT understandability score was 86 (range 58-100) and the average actionability was 90 (range 40-100). Two resources met Flesch-Kincaid reading ease and grade level. Eight were available in English only, nine in two languages, and three in more than two languages. Three explicitly discussed completion of POLST forms. The majority of the resources adequately addressed the content of advanced directives and health care proxy, values, goals, and preferences for future care. The level of time commitment required to use each resource also varied considerably. CONCLUSION: We present a comprehensive evaluation of resources to support ACP. Using the Transtheoretical Model, we provide a guide for the use of these educational resources based on patient readiness. This review allows clinicians to identify aspects of each resource that may be helpful in preparing older adults for future healthcare decsions. Our analysis has identified the need to continue to refine these educational resources so that they can reach a broad population with varying needs. Advance care planning (ACP) conversations help individuals exercise autonomy and make informed decisions about their care. There are many ACP educational resources available to support the process of advance care planning, yet available resources are not universally accepted and under-utilized in clinical practice. We present a comprehensive evaluation of 20 educational resources to support ACP. Educational resources were identified and evaluated for: Patient Education Materials Assessment Tool (PEMAT) score, Flesch-Kincaid reading ease and grade level, cost, languages available, and categories of content. Using the Transtheoretical Model, we provide a guide for the use of these educational resources based on patient readiness. This review allows clinicians to identify aspects of each resource that may be helpful in preparing older adults for future healthcare decisions. Our analysis has identified the need to continue to refine these educational resources so that they can reach a broad population with varying needs.

Occupational Variation in End-of-Life Care Intensity.

BACKGROUND: End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. OBJECTIVE: We investigated occupation as a source of variation in EOL care intensity. METHODS: Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. RESULTS: Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. CONCLUSION: Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.

Effectiveness of narrative pedagogy in developing student nurses' advocacy role.

BACKGROUND: The literature and research on nursing ethics and advocacy has shown that generally very few nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern and that often advocacy in nursing is not learned until after students have graduated and begun working. OBJECTIVE: To evaluate the effectiveness of narrative pedagogy on the development of advocacy in student nurses, as measured by the Protective Nursing Advocacy Scale. DESIGN: We tested the hypothesis that use of a narrative pedagogy assignment related to ethics would improve student nurse's perception of their advocacy role as measured by the Protective Nursing Advocacy Scale using a quasi-experimental nonrandomized study using a pre-test, intervention, post-test design. Data collection occurred during class time from October 2012 to December 2012. The Protective Nursing Advocacy Scale tool was administered to students in class to assess their baseline and was administered again at the completion of the educational intervention to assess whether narrative pedagogy was effective in developing the nursing student's perception of their role as a patient advocate. ETHICAL CONSIDERATIONS: Students were informed that their participation was voluntary and that the data collected would be anonymous and confidential. The survey was not a graded assignment, and students did not receive any incentive to participate. The institutional review board of the college determined the study to be exempt from review. SETTING: School of Nursing at a small liberal arts college in the Northeastern United States. PARTICIPANTS: A consecutive, nonprobability sample of 44 senior-level nursing students enrolled in their final nursing semester was utilized. FINDINGS: Results indicated significant differences in student nurse's perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story. CONCLUSION: Using the Protective Nursing Advocacy Scale, we were able to measure the effectiveness of narrative pedagogy on nursing student's perception of the nurse's advocacy role.

Use of a nursing checklist to facilitate implementation of therapeutic hypothermia after cardiac arrest.

Therapeutic hypothermia has become a widely accepted intervention that is improving neurological outcomes following return of spontaneous circulation after cardiac arrest. This intervention is highly complex but infrequently used, and prompt implementation of the many steps involved, especially achieving the target body temperature, can be difficult. A checklist was introduced to guide nurses in implementing the therapeutic hypothermia protocol during the different phases of the intervention (initiation, maintenance, rewarming, and normothermia) in an intensive care unit. An interprofessional committee began by developing the protocol, a template for an order set, and a shivering algorithm. At first, implementation of the protocol was inconsistent, and a lack of clarity and urgency in managing patients during the different phases of the protocol was apparent. The nursing checklist has provided all of the intensive care nurses with an easy-to-follow reference to facilitate compliance with the required steps in the protocol for therapeutic hypothermia. Observations of practice and feedback from nursing staff in all units confirm the utility of the checklist. Use of the checklist has helped reduce the time from admission to the unit to reaching the target temperature and the time from admission to continuous electroencephalographic monitoring in the cardiac intensive care unit. Evaluation of patients' outcomes as related to compliance with the protocol interventions is ongoing.

A description of nurses' decision-making in managing electrocardiographic monitor alarms.

AIMS AND OBJECTIVES: To describe the cues and factors that nurses use in their decision-making when responding to clinical alarms. BACKGROUND: Alarms are designed to be very sensitive, and as a result, they are not very specific. Lack of adherence to the practice standards for electrocardiographic monitoring in hospital settings has been observed, resulting in overuse of the electrocardiographic monitoring. Monitoring without consideration of clinical indicators uses scarce healthcare resources and may even produce untoward circumstances because of alarm fatigue. With so many false alarms, alarm fatigue represents a symptom of a larger problem. It cannot be fixed until all of the factors that contribute to its existence have been examined. DESIGN: This was a qualitative descriptive study. METHOD: This study was conducted at an academic medical centre located in the Northeast United States. Eight participants were enrolled using purposive sampling. Nurses were observed for two three-hour periods. Following each observation, the nurse was interviewed using the critical decision method to describe the cognitive processes related to the alarm activities. Qualitative data from the conducted interviews were analysed via an a priori framework founded in the critical decision method. RESULTS: This study reveals information, experience, guidance and decision-making as the four prominent categories contributing to nurses' decision-making in relation to alarm management. Managing technology was a category not identified a priori that emerged in the data analysis. CONCLUSION: Nurses revealed a breadth of information needed to adequately identify and interpret monitor alarms, and how they used that information to put the alarms into the particular context of an individual patient's situations. RELEVANCE TO CLINICAL PRACTICE: Understanding the cues and factors nurses use when responding to cardiac alarms will guide the development of learning experiences and inform policies to guide practice.

Nurses' response to frequency and types of electrocardiography alarms in a non-critical care setting: a descriptive study.

BACKGROUND: An important role of the registered nurse is to identify patient deterioration by monitoring the patient condition and vital signs. Increasingly, this is supplemented with continuous electrocardiographic (ECG) monitoring. Continuous monitoring is inefficient in identifying deterioration because of the high number of false and nuisance alarms. Lack of strong evidence or formal guidelines for the care of patients receiving ECG monitoring has led clinicians to rely too heavily on this technology without consideration of its limitations. The nursing workload associated with alarm management remains unexamined. OBJECTIVE: To describe nurses' routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care. METHODS: Design. Prospective, descriptive, observational study. Setting and participants. Between January 2011 and March 2011 we observed nine Registered Nurses providing care for patients receiving continuous ECG monitoring in non-critical care areas. The PI and two research assistants observed each nurse for two 3-h observation periods and recorded data on a researcher designed observation tool. At the end of each observation period, the observers printed the alarm events as recorded by the central monitoring computer. RESULTS: Nurses responded to 46.8% of all alarms. During the observation period, there were no dysrhythmia adverse events. One patient had a change in condition requiring transfer to a higher level of care. A range of nursing interventions occurred in response to alarms. CONCLUSION: Nurses routine practices related to monitoring continue to reveal gaps in practice related to alarm management. Observations of practice also revealed the difficulties and complexities of managing alarm systems and the range of nursing interventions associated with managing alarms.

Use of the critical decision method in nursing research: an integrative review.

The focus of this article is the background and use of the critical decision method in nursing research. The purpose is to present a synthesis of the body of work whose authors used the critical decision method to explore nurses' cognitive work. For this integrative review of literature, I used the 5-step process: problem formulation, literature search, data evaluation, data analysis, and presentation. Synthesis of the 7 studies uncovered evidence of nurses' cognitive processes and demands of their practice environments and affirmed the method as a valuable tool for eliciting experienced nurses' practice knowledge making nursing expertise explicit.

Clinical teleconferencing: bringing the patient to the classroom.

PROBLEM: The confidence to act on clinical judgment, ask for help, and juggle multiple competing priorities is best developed within a clinical setting. Traditional classroom learning, which is often static, does not support learning these skills or help new students learn how to "be" a nurse. Student nurses need frequent and repeated exposure to expert nurses and clinical environments. Traditional teaching methods may not be sufficient to meet these needs. METHOD: This project employs a strategy that supplies situated, context-driven learning with the aim of improving clinical reasoning by bringing real-world, real-time clinical scenarios into the classroom via audio conferencing. This classroom teaching strategy is based on the principles of learner-centered teaching, and the aim is to incorporate real-world clinical information into the classroom. Students are introduced to "real-time report" from special care areas as the basis for class activities and discussion. FINDINGS: Feedback on this model was sought through course evaluation data, focus groups with students, and participating nurses. NCLEX pass rate remained unchanged as a result of this teaching strategy. CONCLUSION: In this model, the classroom changes from being a physical place where knowledge is acquired to a place where knowledge is translated from and applied to practice.

Digital stories: incorporating narrative pedagogy.

An ever-increasingly complex health care environment requires practitioners who can solve clinical problems from a range of perspectives and synthesize multiple sources of knowledge. Narrative pedagogy was the framework for a digital story assignment for a senior-level synthesis and clinical decision making course. This article describes how the use of digital stories enhanced students' clinical thinking strategies from a narrative pedagogy perspective.

Nurse decision making in the prearrest period.

There is a significant body of research demonstrating that many hospitalized patients exhibit signs of clinical deterioration prior to experiencing a cardiopulmonary arrest (CPA).This qualitative study used the critical decision method to describe the cues and factors employed by nurses to identify and interrupt a potentially preventable CPA. The cues that nurses used in identifying a patient at risk for CPA were altered level of consciousness and other selected triggers from the Early Warning Scoring System (EWSS) combined with knowledge of the patient and the contextual features of the decision situation. Nurse characteristics that assisted in interrupting an adverse event included previous experiences in prearrest situations, and the ability to function as part of a team. Organizational characteristics that supported the nurse to interrupt included the availability of nurse-initiated monitoring equipment, experience and flexibility of staff, working with a collaborative team, and access to knowledge resources.