The Influence of Time and Place on the Experiences of US Military Nurses in Vietnam.

BACKGROUND: Although the conflict in Vietnam (usually referred to as the Vietnam War) ended almost 50 years ago, few research-based publications of nurses' experiences in Vietnam exist. PURPOSE: The purpose of this study was to expand what is known about the experiences of US military nurses who served in Vietnam. METHODS: This secondary analysis used qualitative description to examine interview data from 15 nurses who served in-country (within Vietnam) and in-theater supporting Vietnam (e.g., Guam, the Philippines) between 1965 and 1972. FINDINGS: We found that nurses' experiences varied based on time deployed and place deployed (land, sea, or air; in-country or in-theater). The influence of time and place on US military nurses' experiences in Vietnam are illustrated through findings pertaining to danger, daily life, and work. The most prominent differences were between nurses assigned in-country and those assigned in-theater. DISCUSSION: The findings illustrate ways research of more recent and future conflicts might be strengthened.

Exploring the turbulent nature of nurses' workflow.

Turbulence is a central feature of nurses' workflow, yet it has received insufficient attention regarding how it affects nurses' work conditions. To enhance understanding of turbulence, we expanded upon and added refinements to an early conceptualization that included communication and workload as major sources of turbulence. For communication, the contributions of interruptions and handoffs are further explored. For workload, patient turnover and supplies/equipment are further explored; human resources and the built environment were added. Potential consequences of turbulence are also identified including increased cognitive work, increased workarounds, and diminished nurse well-being. Actions to address turbulent workflow include teaching students and nurses strategies to manage turbulence; attending to the practice environment such as staffing composition, remedying longstanding issues with supplies and equipment, and developing technology platforms with nurse input; and suggesting investigations to advance understanding of how turbulence influences nurses and to devise effective interventions.

Characteristics associated with neuropsychiatric symptoms in persons living with dementia and caregiver distress and diminished well-being.

BACKGROUND: The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal. PURPOSE: To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49). METHODOLOGY: Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics. RESULTS: Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life. CONCLUSIONS: Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being. IMPLICATIONS: Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed.

Trajectories of Recovery after Atrial Fibrillation Ablation.

Ablation procedures are common for patients with atrial fibrillation (AF), yet evidence is limited about patient perceptions of their recovery following ablation. We sought to expand understanding of this recovery process. Twenty participants undergoing their first AF ablation completed semi-structured interviews prior to ablation (baseline) and at one, three, and six months post AF ablation. Pre-procedure education is modeled after education used for other ablation procedures, preparing patients to expect a single recovery trajectory. We identified two recovery trajectories that varied in speed of symptom resolution: sustained improvement and pseudo improvement. Recovery was slower than expected in both trajectories. Moreover, returning to desired activity levels consistently lagged behind other symptom resolution by approximately two months. A more accurate understanding of what patients experience post-ablation, as illustrated in these findings, serves as a beginning step to alter patient education prior to AF ablation to better prepare individuals for the recovery process.

Nurse Leader Expertise for Pandemic Management: Highlighting the Essentials.

The COVID-19 pandemic requires military nurse leaders in various patient care settings to engage in disaster response. Evidence supports essential leadership attributes for nurses that include skilled communication, organizational influence, and personnel management. Yet, nursing expertise that shapes nurse leader responsibilities during disaster management remains unclear. A description of how military nurse leaders contributed their nursing expertise during the COVID-19 pandemic response at one U.S. Military health care facility is provided to begin to delineate disaster management responsibilities.

Looking Back to Move Forward: Celebrating the 50th Anniversary of the Association of Leadership Science in Nursing.

This article is based on an invited presentation delivered in celebration of the 50th anniversary of the Association of Leadership Science in Nursing. The article begins with framing the historical context of nursing administration/leadership. The look-back includes a glimpse at the evolution of the Council on Graduate Education for Administrative Nursing into the Association of Leadership Science in Nursing. Two present-day leadership issues are then considered-turbulence and interprofessional proficiency. Lastly, the concept of problematizing is proposed as a strategy for moving forward. Yesterday, today, and tomorrow though are not tidy packages with good boundaries. The chronology, therefore, is not always linear.

Caregivers' Experience at an Integrated Memory Care Clinic.

The Integrated Memory Care Clinic is a patient-centered medical home led by advanced practice RNs (APRNs) who provide dementia care and primary care simultaneously and continuously. We explored the experiences of 12 informal caregivers of persons living with dementia during their first year at the Clinic. Data were analyzed via directed content analysis. Caregivers described the Clinic as "the only place you should go to for dementia [care]." Caregivers felt a sense of belonging to the Clinic, valued APRNs' competence and staff's dedication, and round-the-clock telephone access to APRNs. Caregivers also acknowledged that "we're all out here swimming on our own." They expressed their sense of being overwhelmed and needing more services and medical and non-medical resources, and more prognostic information on dementia. Although the Clinic is beneficial for caregivers, caregiving demands exceed the supply of services and resources at the Clinic. [Research in Gerontological Nursing, 14(2), 69-78.].

Adherence trajectories in oral therapy for chronic myeloid leukemia: Overview of a research protocol.

Over a quarter of chemotherapy regimens now include oral agents. Individuals living with cancer are now responsible for administering this lifesaving therapy at home by taking every dose as prescribed. One type of oral chemotherapy, tyrosine kinase inhibitors (TKIs), is the current recommended treatment for chronic myeloid leukemia. This targeted therapy has markedly improved survival but comes with significant side effects and financial costs. In the study described in this protocol, the investigators seek to understand the dynamic nature of TKI adherence experienced by individuals diagnosed with CML. Using a mixed-method approach in this prospective observational study, funded by the National Cancer Institute, we seek to describe subjects' adherence trajectories over 1 year. We aim to characterize adherence trajectories in individuals taking TKIs using model-based cluster analysis. Next, we will determine how side effects and financial toxicity influence adherence trajectories. Then we will examine the influence of TKI adherence trajectories on disease outcomes. Additionally, we will explore the experience of patients taking TKIs by interviewing a subset of participants in different adherence trajectories. The projected sample includes 120 individuals taking TKIs who we will assess monthly for 12 months, measuring adherence with an objective measure (Medication Event Monitoring System). Identifying differential trajectories of adherence for TKIs is important for detecting subgroups at the highest risk of nonadherence and will support designing targeted interventions. Results from this study can potentially translate to other oral agents to improve care across different types of cancer.

Patient and caregiver outcomes at the integrated memory care clinic.

The purpose of this longitudinal cohort study was to explore the outcomes of persons living with dementia (PLWD) and their caregivers during their first 9 months at the Integrated Memory Care Clinic (IMCC). IMCC advanced practice registered nurses provide dementia care and primary care simultaneously and continuously to PLWD until institutionalization. Changes were examined in caregivers' psychological well-being (perceived stress, depressive symptoms, caregiver burden, and anxiety) and health status and in PLWDs' quality of life and neuropsychiatric symptoms. Data were collected at baseline, then 3 and 6 months post-baseline. Forty-two caregivers completed all 3 assessments. Most variables remained unchanged. Statistically significant improvements in 5 sub-scales of the Neuropsychiatric Inventory were observed: caregivers' distress regarding their PLWDs' delusions and anxiety, and PLWDs' severity of delusions, depression, and total symptom severity. Further testing of the IMCC is required, including in quasi-experimental studies, to determine its efficacy.

From fear to fortitude: Using the power within the nursing profession to fight COVID-19.

Communicating is essential. The communication chain within units and facilities must be kept strong. Good communication will help staff take responsibility for one another; knowing your work family is looking out for you can offer strength. Respecting each other encourages speaking up to create a platform for shared decision-making and problem-solving. Such shared responsibility will yield the best solutions because the whole is stronger together than individuals alone. Speaking up also is a way to offer immediate feedback if mistakes are observed so that errors are corrected. And when, not if, mistakes are made, staff need to be able to communicate these without fear of retribution.

Comfort in Labor: "Like Being Able to Exhale".

Comfort is a fundamental human need to seek relief, ease, and transcendence. Comfort is relevant to women in labor who experience intense pain and mixed emotions. The subjective meaning of comfort in labor for women is not fully understood. This work was part of a phenomenological study of the experience of childbirth, in which the dynamic of keeping-it-together-falling-apart was identified as an essential quality of women's perceptions of childbirth. Comfort was a salient element of keeping-it-together-falling-apart. In this report, the concept of comfort is explored in greater depth, using qualitative descriptive analysis. Eight participants, aged 23 to 38 years, with spontaneous vaginal births, were each interviewed twice about the childbirth experience. Comfort was a holistic experience of relaxation and relief, where the needs of the body and the person were being met. Comfort and pain coexisted with each other, and relief of pain did not always provide comfort. Women had an innate knowledge of comfort, but their capacity for choice was at times restricted by caregivers in the hospital. There are aspects of labor care that do not support comfort, particularly as it relates to mobility and choice. Prioritizing comfort as well as pain relief may contribute to a more holistic, satisfying birth experience for women.

Ethological observations of social behavior in the operating room.

Operating rooms (ORs) are inhabited by hierarchical, mixed-gender clinical teams that are often prone to conflict. In evolutionary terms, one expects more within- than between-gender rivalries, especially since the OR is a place where all sorts of social interactions occur, not merely technical communications. To document the full range of behavior, the present study used ethological observation techniques, recording live all social behavior by the team. Using an ethogram, 6,348 spontaneous social interactions and nontechnical communications were timestamped during 200 surgical procedures. Cooperation sequences (59.0%) were more frequent than conflict sequences (2.8%), which ranged from constructive differences of opinion to discord and distraction that could jeopardize patient safety. Behavior varied by clinical role and with the gender composition in the OR. Conflict was initiated mostly down the hierarchy between individuals several ranks apart. Cooperation tended to increase with a rising proportion of females in the OR, but the most pronounced effect concerned the interaction between both genders. If the attending surgeon's gender differed from that of the majority of other personnel in the OR, cooperation was significantly more common.

Enacting high reliability principles while caring for people with Ebola Virus Disease.

BACKGROUND: Fear surrounds Ebola Virus Disease (EVD) because it is highly infectious. Yet members of the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital (EUH) had to overcome that fear when caring for patients with EVD. PURPOSE: The analysis reported here illustrates how the members of EUH's SCDU tacitly enacted high reliability (HR) principles while caring for patients with EVD. METHODS: A qualitative study was conducted to describe the experience of members of the EUH SCDU who worked with EVD patients in 2014. We completed 17 semi-structured interviews involving registered nurses, physicians, and support personnel (eg, laboratory technicians). Interview recordings were transcribed and analyzed using conventional content analysis. Exploring HR principles was not among the questions guiding this exploration, but the participants repeatedly described concepts related to HR. RESULTS: The goal of the SCDU team was to save patients' lives while protecting their own lives. Rigorous training and meeting high standards were required to make the team. The fear surrounding EVD set in motion the enactment of HR principles. HR principles served to alleviate failures or breakdowns in infection prevention and control, thus keeping patients and staff safe. CONCLUSIONS: These findings illustrate that it is possible to move HR principles from theory to practice in high-risk situations. HR principles were essential to safety and to infection prevention and control.

A systematic review of pediatric self-report symptom measures: Congruence with the theory of unpleasant symptoms.

PURPOSE: Many children and adolescents experience unpleasant symptoms due to acute and chronic illnesses. Several symptom measures specific to children and adolescents are available to assess unpleasant symptoms. What is unclear is how well these measures assess all dimensions of the symptom experience. Using the Theory of Unpleasant Symptoms (TOUS) as a guide, the purpose of this systematic review of self-report symptom measures was to examine the comprehensiveness of current symptom measures designed to assess children's and adolescents' symptom experiences. CONCLUSIONS: The TOUS did not guide the development of any of the measures studied; hence, exact parallels were not expected. Currently, no pediatric self-report symptom measures were found that assessed all dimensions of the symptom experience. Four measures captured three dimensions: intensity, timing, and distress. Only two measures assessed quality. PRACTICE IMPLICATIONS: Practitioners need to be aware of the dimensions reflected in commonly used symptom measures. Augmentation of these measures is needed in order to assess the entire symptom experience in children and adolescents.

Keeping it together and falling apart: Women's dynamic experience of birth.

OBJECTIVE: To explore the complexity of women's birth experiences in the context in which they occur and to describe how these influence women's well-being in labor. DESIGN: Qualitative method with a phenomenological approach, following the analysis principles of van Manen. PARTICIPANTS AND SETTING: Eight women from different ethnic and socioeconomic backgrounds in Atlanta, Georgia, United States with a recent, healthy birth were interviewed twice about their experience of the labor journey. The first interview was 3-12 weeks post-partum, with the second interview at 10-22 weeks post-partum. FINDINGS: The phenomenon of childbirth was a dynamic fluctuating between keeping it together and falling apart. The changes in emotion were created by a sensitive feedback loop between the woman and her environment, the physical space, and interactions with humans present. Four characteristics supported and created this phenomenon: confidence, comfort, agency and connection. Confidence was believing in one's physical ability to birth the baby while at the same time, having the emotional resources to cope with the experience. Comfort was essential to manage pain and difficult emotions. The presence of comfort changed the meaning and experience of pain and increased relaxation. Agency was overtly supported in labor, but compromised by hospital routine and unresponsive caregiver practices, and was diminished by women's vulnerability in labor. When agency was compromised, falling apart increased, and there was a move towards intense negative emotion. In labor, women wanted an authentic human connection, being known as a person. This connection was a mechanism to support the other characteristics of comfort, confidence, and agency. IMPLICATIONS FOR PRACTICE: Clinicians need to accommodate the complex, dynamic fluctuations of emotion during birth addressing both the physical and non-physical aspects of the person. Birth care practices and childbirth research need to account for the complexity of birth as a holistic experience, specifically regarding the emotional shifts as well as the women's sensitivity to the environment and everything contained in it. There is a need for more research related to the dynamics of emotional changes in labor, how these changes affect labor physiology and influence normal birth and birth outcomes.

Twenty years of staffing, practice environment, and outcomes research in military nursing.

BACKGROUND: Two decades ago, findings from an Institute of Medicine (IOM) report sparked the urgent need for evidence supporting relationships between nurse staffing and patient outcomes. PURPOSE: This article provides an overview of nurse staffing, practice environment, and patient outcomes research, with an emphasis on findings from military studies. Lessons learned also are enumerated. METHOD: This study is a review of the entire Military Nursing Outcomes Database (MilNOD) program of research. DISCUSSION: The MilNOD, in combination with evidence from other health care studies, provides nurses and leaders with information about the associations between staffing, patient outcomes, and the professional practice environment of nursing in the military. Leaders, therefore, have useful empirical evidence to make data-driven decisions. The MilNOD studies are the basis for the current Army nursing dashboard, and care delivery framework, called the Patent CaringTouch System. CONCLUSION: Future research is needed to identify ideal staffing based on workload demands, and provide leaders with factors to consider when operationalizing staffing recommendations.

Understanding deployment from the perspective of those who have served.

BACKGROUND: The term deployment is used by the military to describe sending troops to carry out a combat, peacekeeping, or humanitarian mission. PURPOSE: The purpose of this analysis was to illustrate the variations around combat deployment experiences. METHODS: Qualitative descriptive methodology was used to examine data from 17 members of the U.S. military who deployed at least once to a combat zone after the September 11, 2001 attacks. FINDINGS: No two deployments were the same between individuals or within individuals if they deployed more than once. Variations were discovered in deployment experiences related to deployment demands, deployment resources, and coming back changed as individuals. CONCLUSIONS: Regarding deployment as a singular concept does not take into account the variations in the deployment experience. Individuals caring for those who have served in war would benefit from understanding that each deployment is unique and a life-altering experience.