Human Factors Contributing to Infection Prevention in Outpatient Hemodialysis Centers: A Mixed Methods Study.

RATIONALE & OBJECTIVE: Infection prevention efforts in dialysis centers can avert patient morbidity and mortality but are challenging to implement. The objective of this study was to better understand how the design of the work system might contribute to infection prevention in outpatient dialysis centers. STUDY DESIGN: Mixed methods, observational study. SETTING & PARTICIPANTS: Six dialysis facilities across the United States visited by a multidisciplinary team over 8 months. ANALYTICAL APPROACH: At each facility, structured macroergonomic observations were undertaken by a multidisciplinary team using the SEIPS 1.0 model. Ethnographic observations were collected about staff encounters with dialysis patients including the content of staff conversations. Selective and axial coding were used for qualitative analysis and quantitative data were reported using descriptive statistics. RESULTS: Organizational and sociotechnical barriers and facilitators to infection prevention in the outpatient dialysis setting were identified. Features related to human performance, (eg, alarms, interruptions, and task stacking), work system design (eg, physical space, scheduling, leadership, and culture), and extrinsic factors (eg, patient-related characteristics) were identified. LIMITATIONS: This was an exploratory evaluation with a small sample size. CONCLUSIONS: This study used a systematic macroergonomic approach in multiple outpatient dialysis facilities to identify infection prevention barriers and facilitators related to human performance. Several features common across facilities were identified that may influence infection prevention in outpatient care and warrant further exploration.

Crisis Counselors' Perceptions and Assessment of Suicidal Behavior Among Hurricane Survivors Receiving Crisis Counseling Services.

OBJECTIVE: The aims of this study were to assess the awareness of risk for suicidal behaviors and perspectives of Project Recovery counselors who provided crisis counseling services to hurricane survivors. METHODS: The Short Posttraumatic Stress Disorder Rating Interview-Extended, a quantitative disaster mental health measure, was used to assess distress and dysfunction to the recent hurricanes. Project Recovery counselor data were collected through a 22-item qualitative interview. RESULTS: Seven out of 207 clients (3.4%) endorsed the quantitative item measuring suicidal ideation. Clients who reported suicidal ideation had significantly higher scores on items indicating a loss of enjoyment, feelings of depression, feeling less able to handle stress, and other mental health items. Counselor responses fell into 5 major themes: Assessment and Action, Client Characteristics, Services, Counselor Training and Preparedness, and Future Directions. CONCLUSIONS: Suicidal behavior is a serious mental health emergency, yet it remains a challenging issue as suicidal behaviors are complex and disaster survivors with suicidal ideation may experience intense psychological reactions to the event. In order to provide competent care to survivors experiencing suicidal thoughts or behaviors, the need for counselors to receive adequate training in suicide assessment and management is essential.

The within-day relation between lonely episodes and subsequent clinical pain in individuals with fibromyalgia: Mediating role of pain cognitions.

OBJECTIVE: This daily diary study of individuals with fibromyalgia (FM) examined whether morning increases in loneliness relate to worsened evening bodily pain through afternoon negative pain cognitions. METHODS: 220 participants with FM completed electronic diaries 4 times a day for 21days to assess loneliness, negative pain cognitions, bodily pain, and social enjoyment. Multilevel structural equation modeling was used to examine within-person relations of morning increases in loneliness, afternoon negative pain cognitions, and evening pain, controlling for morning pain. RESULTS: On mornings when individuals experienced higher than their usual levels of loneliness, they experienced higher levels of afternoon maladaptive pain cognitions, which in turn predicted increases in evening pain above the level of morning pain. Afternoon maladaptive pain cognitions fully mediated the relations between morning loneliness and evening pain. CONCLUSIONS: Lonely episodes are associated with subsequent increases in negative patterns of thinking about pain, which in turn predict subsequent increases in bodily pain within a day. Because pain cognitions mediate the loneliness-pain link, FM interventions may benefit from addressing individuals' vulnerability to maladaptive cognitions following lonely episodes.

Mindfulness and cognitive-behavioral interventions for chronic pain: differential effects on daily pain reactivity and stress reactivity.

OBJECTIVE: This study compared the impact of cognitive-behavioral therapy for pain (CBT-P), mindful awareness and acceptance treatment (M), and arthritis education (E) on day-to-day pain- and stress-related changes in cognitions, symptoms, and affect among adults with rheumatoid arthritis (RA). METHOD: One hundred forty-three RA patients were randomized to 1 of the 3 treatment conditions. CBT-P targeted pain-coping skills; M targeted awareness and acceptance of current experience to enhance coping with a range of aversive experiences; E provided information regarding RA pain and its management. At pre- and posttreatment, participants completed 30 consecutive evening diaries assessing that day's pain, fatigue, pain-related catastrophizing and perceived control, morning disability, and serene and anxious affects. RESULTS: Multilevel models compared groups in the magnitude of within-person change in daily pain and stress reactivity from pre- to posttreatment. M yielded greater reductions than did CBT-P and E in daily pain-related catastrophizing, morning disability, and fatigue and greater reductions in daily stress-related anxious affect. CBT-P yielded less pronounced declines in daily pain-related perceived control than did M and E. CONCLUSIONS: For individuals with RA, M produces the broadest improvements in daily pain and stress reactivity relative to CBT-P and E. These findings also highlight the utility of a diary-based approach to evaluating the treatment-related changes in responses to daily life.

Describing nurses' work: combining quantitative and qualitative analysis.

OBJECTIVE: To better understand nursing activities and working conditions. BACKGROUND: Nursing practice involves astute clinical decision making and the competent delivery of nursing care procedures. To complete nursing procedures, nurses must simultaneously organize and reorganize priorities and manage changing clinical information for multiple patients. Few researchers have examined the specific nature of nurses' activities and the effect of the environment on their work. METHODS: Quantitative and qualitative methods were used to collect data on 7 nurses engaged in nursing activities. Examples of methods include link analysis, subject matter expert, task analysis, cognitive pathway, and "stacking." Data collection focused on how nurses managed priorities, changing clinical information, and interruptions. RESULTS: The "cognitive pathway" graphically depicts the nature of nurses' work. Specifically, it reveals the shifting of the nurse's attention from patient to patient and the occurrence of interruptions. "Stacking" shows the number of tasks a nurse must balance at any one time. On average, nurses had 10 or more activities waiting to be performed and experienced 3.4 interruptions/hr. CONCLUSION: These methods provide unique insight into the dynamic nature of patient care and nursing work. APPLICATION: Extension of the methods demonstrated here may be useful in guiding efforts to change the work of nursing to better provide quality care and less stressful work environments.