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With specific tasks to fulfill, physicians often interact superficially with patients and their families to provide health care in the form of diagnosis and treatment. They miss so-called hallway conversations that may contain important information about the patient and family’s mental and social well-being. How, then, are they able to comprehensively address the more cryptic effects of cancer therapy that are not directly related to their patient’s physical health? In this study, a team of pre-clinical medical students analyzed 120 narrative journals written over an 11-year period by 119 3rd and 4th -year medical students who shadowed patients and their families in the pediatric hematology/oncology department of an academic medical center. These students did not fulfill clinical duties but learned about the cancer experience by shadowing pediatric patients and their families. The goal of this narrative study was to analyze these journals for content that revealed experiences of patients and their families that are not necessarily recognized by the healthcare team. These students were often involved in the most intimate moments of the cancer journey: receiving bad news, witnessing a child’s pain, and dealing with the death of a loved one. These experiences allowed the students to describe reactions that are often unobserved using narrative writing. With this information, multi-faceted treatment plans that go beyond the physical health of the child can be developed that incorporate the more obscure psychosocial, mental, and emotional health needs. This narrative style may also serve as a novel strategy for future clinical rotations.

Over the course of medical school, students’ optimism and hopefulness often devolve into a cynical view of medicine that continues throughout clinical rotations and beyond (Neumann et al., Acad Med 86(8):996–1009, 2011). Here, we present a qualitative evaluation of a novel immersive elective in pediatric psycho-oncology coupled with narrative medicine and its impact on students. Participants were third- and fourth-year medical students who were relieved of traditional clinical duties. Alternatively, they shadowed pediatric cancer patients, keeping narrative journals of their observations and insights. A trained team of pre-clinical medical students and faculty conducted a retrospective analysis of 120 journals written between 2008 and 2019. They compared recurring concepts to assess how blending experiential learning and reflective writing influenced the attitudes and behaviors of students. Consistent themes emerged related to developing a rich understanding of patient experiences, a humanistic appreciation of the context of illness, the ability to meaningfully reflect on insights to critically ill children, and an appreciation for the unique learning opportunity. Additionally, families expressed gratitude for the students’ attentiveness to their emotional needs. By the conclusion of the elective, most students discovered that they had reignited their intrinsic empathic behaviors and were provided with beneficial insights that they believed would continue into future rotations. Experiential teaching methods paired with narrative reflection may be a valuable and therapeutic tool to learn the intricacies of the patient perspective, with the potential to enhance humanism in students during a critical time in their medical training when empathy tends to drift. Longitudinal and quantitative studies are warranted to better understand the degree and duration of specific benefits.

In critical care units, distressing events related to patient and family-centered care can influence job dissatisfaction and emotional distress.1-8 Strategies for processing difficult incidents are limited, creating a need for standardized real-time debriefing tools. This study evaluated an innovative nurse-led program that was developed and piloted in one acute care unit of a large academic medical center. An evidence-based practice nurse-led debriefing process provided a sequential process for facilitation of an interdisciplinary group after the occurrence of a distressing event. Throughout a 2-year period, 104 real-time debriefings (>380 staff participation) took place. Emergent situations precipitated the most debriefings followed by disruptive patient/family behavior. Over 80% of the participants affirmed the debriefing process was beneficial, assisted them in coping with the traumatic event, and recommended this type of debriefing to others. These results show that members of an interdisciplinary team will engage in a brief (∼10 minute) nurse-led debriefing program when offered the opportunity to do so, and that this intervention was successful beyond the acute care unit where it originated.

BackgroundPatient bias and prejudice directed against physicians from diverse backgrounds is a frequent occurrence in healthcare. Female physicians have long experienced discrimination in the healthcare system based on their gender alone. The dynamic known as Patient Prejudice toward Providers (PPtP) is disproportionately affecting female physicians because it is frequently compounded by sexism.AimThe goal of this study was to explore the impact of PPtP on female resident and attending physicians.MethodsUsing transcribed one-on-one interviews from a larger study of PPtP affecting resident and attending physicians, ten interviews with female physicians (resident and attending) from diverse ethnic backgrounds and countries of training at a large academic medical center were analyzed. The authors independently reviewed the interviews using an iterative process within and across interviews to inductively identify repeating words, phrases, and concepts relevant to the study aim.ResultsDemographics of the ten participants included age (mean 34.6 years), ethnicity (6 Asian, 2 Hispanic, 2 African), and country of training (10% IMG vs. 90% US trained). Four of the interviewees were residents and six were attendings. Themes that emerged from the analysis included experiencing “A Gendered Continuum of Abuse,” “Establishing a Higher Standard of Competency,” “Overcoming the Stereotype of the White Male Physician,” “The Physicality of Self Identity,” and “The Need to be Protective of Minoritized Trainees.” All participants agreed that these perceptions created an adverse environment at the workplace and impacted on patient care.ConclusionsDiscrimination of physicians based on their gender or their race/ethnicity has been reported. This study highlights the compounded effects of patient prejudice on female minoritized physicians. Organizations and individuals should identify and implement strategies to address the impact of PPtP and sexism in order to create an environment where all women can thrive professionally.

Background The ANA Code of Ethics for Nurses, regularly revised since 1896, may not provide guidance in an era of pandemic and sociopolitical unrest. Purpose This study explored whether the Code of Ethics comprehensively address current nursing challenges. Methods 23 nurses participated in six Zoom focus groups to discuss whether provisions were applicable to their current practice. An iterative approach was used to review transcripts independently and then merge findings to identify ethical themes. Findings Provisions 4, 6, and 8 were most relevant. None of the provisions addressed the guilt secondary to isolating patients from support systems and not being “on the front lines” of COVID care. Discussion The co-occurring crises of COVID-19 and social unrest created an ethical crisis for many nurses. The Code of Ethics provided a useful guide for framing discussion and formulating strategies for change, but did not eliminate distress during a time of novel challenges.

Background: Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication. Objective: Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability. Methods: A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed. Results: In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups. Conclusion: This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

Evidence-based care is standard practice in medicine, but the patient gown has fallen outside the scope of scholarly research. The current gown renders a patient vulnerable, diminishing patients’ sense of identity, agency, and dignity with its one-size-fits-none design. The impact on providers is similarly neglected. Our objective was to explore how patients and providers derive meaning from patient gowns. A convenience sample at an academic medical center was interviewed utilizing a standardized framework developed by a medical student and two PhD-prepared researchers with experience in qualitative methods. The study was inductive in nature, seeking to understand perceptions of the patient gown through thematic analysis of transcripts within and across interviews. Participants were ten patients (5 women, 5 men; mean (SD) age = 56.4 (19.1)) years, ten nurses (9 women, 1 man; mean (SD) age = 36.5 (13.4)) years, and ten physicians (6 women, 4 men; mean (SD) age = 48.6 (14.4)) years. Themes within patients’ interviews suggest gowns are provider-driven, the design is problematic, gowns reduce self-esteem, and color options would be empowering. Themes within providers’ interviews addressed gowns theoretically vs. practically, attire biases, and distress from seeing patients in gowns. Common themes among groups included: negative first impressions of gowns, ideas for improvement, and barriers to change. This is the first study to ascertain how patients and providers perceive patient gowns and offer the opportunity to describe and sketch an “ideal” alternative. The current gown satisfies neither patients nor providers, and flaws must be addressed to improve patient and provider experiences. Experience Framework This article is associated with the Environment & Hospitality lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this lens.

Background: Fruit and vegetable prescription (FVRx) programs provide “prescriptions” for produce, but increased access to nutritional food may be insufficient for long-term behavior change. Purpose: We integrated nutritional education into an FVRx program at a farmers' market and community garden at Penn State Medical Center by pairing medical student “mentors” with 4 families with overweight/obese children. Methods: Each head of household completed a presurvey that included basic demographic information, as well as a question about barriers to healthy eating. Families made up to 4 visits to the market with mentors, during which students discussed and documented produce utilization. A 1-hour focus group with mentors was conducted and transcribed. Thematic analysis was performed on qualitative data. Results: Two families completed all visits. On average, families spent 32 minutes at the market/garden per visit, had expenditures of $40.68, and reported one weekly produce item going unused. Families valued o...

Objective To determine how primary care versus specialist practitioners assess and treat school-aged children with irritability. Methods Seventeen providers from family medicine, pediatrics, and psychiatry participated in in-depth interviews from June to August 2016 about the process they use to evaluate irritability. Data on demographic traits and measures of confidence were also collected. Results Primary care (family medicine and pediatrics) participants expressed frustration over the lack of time and specialized knowledge they had to accurately assess children with irritability, even though they were often the first clinician consulted when problems arose. There were clear and sometimes contradictory differences between how practitioners with a general versus specialized practice assessed mental health status in the clinic setting. Input on treatment approaches revealed that medication prescription was more common by primary care participants, and therapy was preferred by the psychiatry participants. Conclusions Overall, family medicine and pediatric practitioners were significantly less confident in their ability to evaluate mental health status, while child and adolescent psychiatry participants were supportive of having more initial triage and possible treatment occur at the primary care level, suggesting a need for more training about childhood irritability in the primary care setting.

Background Childcare providers are often “first responders” for suspected child abuse, and how they understand the concept of “reasonable suspicion” will influence their decisions regarding which warning signs warrant reporting.

Currently, the national dialogue on components of the healthy work environment (WE) in healthcare has taken on new urgency. When a nurse leaves a unit due to an unhealthy WE, it is extremely costly with orientation of a new nurse costing approximately $60,000 (1). In addition to financial costs, there are also patient-care concerns. Poor WEs have been shown to increase the odds of patient death and failure-to-rescue (2) and are related to lower patient satisfaction (3). Administrators and managers have begun to consider strategies for promoting a more fulfilling and productive WE, but often feel poorly prepared to address conflict in the workplace (4). Relational Aggression (RA) occurs when someone uses a relationship rather than physical means to inflict social harm. RA is sometimes known as female bullying, incivility, or “mean girls,” and is more common among women than men, especially during the formative adolescent years (5). Although the study of RA began with work in children, recently, authors have begun to examine this construct and its correlates in adults (6). RA among nurses is of special interest because nursing remains predominately a female profession (7). In general, 3 different roles are associated with RA (8). The aggressor is 1 or more persons in the position of launching an attack; victim(s) are the intended target. Bystanders see the aggression and do not intervene (8). It would be overly simplistic to characterize an individual as 1 of the above because in reality these roles are most often fluid, with yesterday's victims becoming today's aggressors. The largest group appears to be bystanders, who witness abuse--possibly encourage it--and fear that if they intervene, they will become the next target (8). RA is related to a number of similar social phenomena, including bullying, workplace incivility, lateral violence and horizontal violence (9). Scholars sometimes use these words interchangeably, and a clear demarcation of language is sorely needed. For the present study, we understand RA to be broader than similar concepts, since it includes bystander and victim roles in addition to aggressor roles. Prior research has explored the frequency of workplace mistreatment in nurses. Some scholars find high rates of mistreatment: 1 study found that up to 25% of New York State nurses were often or frequently the victim of horizontal violence (10), and another study found that 38% of nurses witnessed horizontal hostility (HH) or bullying behaviors weekly or daily (11). Other research reported low levels of workplace mistreatment. In 1 of the 1st studies on workplace bullying in nurses, Johnson and Rea (2009) found that only 18% of their sample responded in the affirmative when asked if they had ever been bullied at work (6). A recent study found that new graduate nurses experience bullying only every now and then (mean bullying score was 1.57 on a 5-point Likert scale) (12). Finally, a study on workplace incivility found that nurses reported very little workplace incivility from their supervisors or their colleagues: the mean supervisor incivility score was .66, and the mean colleague incivility score was .81—both less than 1 on a 7-point scale (13). These mixed findings point toward a few different interpretations. It is possible that most nurses do not experience workplace mistreatment, but that it is a frequent experience for a small minority. Another possibility is that most nurses do experience workplace mistreatment, but only infrequently. Findings from Lewis and Malecha (2011) support this second perspective: their study showed that 85% of nurses reported experiencing workplace incivility in the last 12 months (14). Scales explicitly measuring RA have been put forth in the literature. The 1st RA instrument for adults was the Peer Assessment of RA and Social Adjustment scale, which consists of 24 items, including one 7-item sub-scale designed to measure relationally aggressive behavior (15). This was followed by the Self-Report of Aggression and Social Behavior (SRASBM), a 39-item measure that examines physical aggression, RA, relational victimization, and exclusivity (16; 17). The RA Assessment Scale (RAAS), which was the best available scale for the present study, does overlap in some ways with these other measures. However, in addition to being oriented toward a work setting and toward RA—and being gender neutral—the RAAS includes the “bystander” category, a common and under-studied group on the RA spectrum and in work mistreatment in general (18). Since work mistreatment is associated with a number of adverse effects, including nurse retention, burnout, productivity, job satisfaction and emotional exhaustion, further study of the emotional work environment is warranted (11 - 14). RA has been shown to be associated with adverse physical and mental outcomes in other populations (5; 16), and anecdotal evidence suggests that nurses who experience RA suffer from problems such as depression, anxiety, somatic symptoms, hypertension, and other negative health consequences (19; 20). Nurses who are involved in RA may leave their jobs prematurely, take extra sick days, and even deliver sub-par patient care (21; 22). Since job satisfaction and intent to remain on the job can be impacted by RA, it was the purpose of this study to explore these concepts in a large sample of nurses.

This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups ( N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient’s goals, values, and preferences into an actionable medical plan. [ Journal of Psychosocial Nursing and Mental Health Services, 52 (2), 38–44.]

Objective—To determine if the addition of nurse case managers (NCMs) trained in motivational interviewing (MI) to usual care would result in improved outcomes in high risk type 2 diabetes patients. Methods—A 2-year randomized controlled pragmatic trial randomized 545 patients to usual care control (n=313) or those who received the intervention (n= 232) with additional practice embedded NCM care, including MI-guided behavior change counseling. NCMs received intensive MI training with ongoing fidelity assessment. Results—Systolic BP was better in the intervention group (131±15.9 vs. 135±18.2, p < 0.05). HbA1c, LDL, and diastolic BP improved in both groups: HbA1c (control group 9.1% to 8.0%, intervention group 8.8% to 7.8%), LDL (control group 127 to 100 mg/dL, intervention group 128 to 102 mg/dL), diastolic BP (control group 78 to 74 mm Hg, intervention group 80 to 74 mm Hg). Depression symptom scores were better in the intervention group. The reduction in diabetesrelated distress approached statistical significance. Conclusions—NCMs and MI improved systolic BP and complications screening. The large decrease in HbA1C and LDL in the control group may have obscured any further intervention effect. Although nurses prompted providers for medication titration, strategies to reduce provider clinical inertia might also be needed. Significant findings of the study—In patients with type 2 diabetes, an intervention with nurse case management and motivational interviewing improves systolic blood pressure, depression, and screening for complications.

The goal of this article is to describe the concept of irritability in children and youth, which has been revisited in the DSM-5. Traditionally, this behavior has been more commonly associated with mood disorders, which may account for the rising incidence of bipolar disorder diagnosis and overuse of mood-stabilizing medications in pediatric patients. While not predictive of mania, persistent nonepisodic irritability, if undetected, may escalate to violent behavior with potentially serious outcomes. It is therefore important to educate clinicians about how to accurately assess irritability in pediatric patients. Language: en

This study examined how Pennsylvania pediatricians characterized reasonable suspicion of child abuse, using their own words in open-ended queries. Content analysis and an iterative process identified themes, which then served as the dependent variable for analysis. 1,249 pediatricians returned the survey (61% response rate), of whom 1,012 answered the open-ended question (49% response rate). Content analysis identified 4 distinct theme categories and significant correlations with age, gender, frequency of reporting, prior education, and current position, but not expertise with child abuse or board certification. These findings add new, qualitative data to arguments for re-examining the threshold for mandated reporting.

Aim To determine how patients with type 2 DM feel about a motivational interviewing (MI) intervention designed to promote positive behavior change. Method Qualitative study using focus groups conducted by the same facilitator. Setting Family or general internal medicine practice clinics affiliated with an academic medical center and a community general hospital. One site consisted of primarily low income Hispanic patients. Participants Four focus groups consisting of nineteen adult patients with type 2 diabetes mellitus solicited from a large NIH-funded randomized controlled trial on MI and diabetes. Results Across and within group analysis was performed on transcripts of the taped interviews. Patient perceptions of standard care were largely negative, with several individuals describing paternalistic and demeaning attitudes. Five themes related to MI emerged: Nonjudgmental Accountability, Being Heard and Responded to as a Person, Encouragement and Empowerment, Collaborative Action Planning and Goal Setting, and Coaching rather than Critiquing. Conclusions Some patients with type 2 diabetes are receptive to motivational interviewing which is a provider approach that is more patient-centered and empowering than traditional care.

Background Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample. Purpose To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance. Methods Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined. Results Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance. Conclusions Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.

Background: Social media strategies in education have gained attention for undergraduate students, but there has been relatively little application with graduate populations in medicine. Aims: To use and evaluate the integration of new social media tools into the curricula of two graduate-level medical humanities electives offered to 4th-year students at Penn State College of Medicine. Methods: Instructors selected five social media tools – Twitter, YouTube, Flickr, blogging and Skype – to promote student learning. At the conclusion of each course, students provided quantitative and qualitative course evaluation. Results: Students gave high favourability ratings to both courses, and expressed that the integration of social media into coursework augmented learning and collaboration. Others identified challenges including: demands on time, concerns about privacy and lack of facility with technology. Integrating social media tools into class activities appeared to offer manifold benefits over traditional classroom methods, including real-time communication outside of the classroom, connecting with medical experts, collaborative opportunities and enhanced creativity. Conclusions: Social media can augment learning opportunities within humanities curriculum in medical schools, and help students acquire tools and skill-sets for problem solving, networking, and collaboration. Command of technologies will be increasingly important to the practice of medicine in the twenty-first century.

Background: Advance care planning (ACP) is an underutilized process that involves thinking about what kind of life-prolonging medical care one would want should the need arise, identifying a spokesperson, and then communicating these wishes. Objective: To better understand what influences individuals to engage in ACP. Design: Three focus groups using semistructured interactive interviews were conducted with 23 older individuals from 3 diverse populations in central Pennsylvania. Results: Four categories of influences for engaging in ACP were identified: (1) concern for self; (2) concern for others; (3) expectations about the impact of ACP; and (4) anecdotes, stories, and experiences. Conclusions: The motivations for undertaking ACP that we have identified offer health care providers insight into effective strategies for facilitating the process of ACP with their patients.

OverviewRelational aggression is a type of bullying typified by various forms of psychological (rather than physical) abuse. It includes such behaviors as gossiping, withholding information, and ostracism. Although relational aggression in girls has garnered considerable interest, scant research on

In the 1970s, the field of medical humanities developed and included ethics, literature, history, integrative medicine, and other topics, most often described from a physician’s perspective. During this same period of revolutionary changes in health care, nursing curricula did not seek to emphasize content in humanities, perhaps because stereotypical views of nursing as the bcaring professionQ made such coursework seem redundant. In 2001, as a result of the Institute of Medicine’s call for all health professionals to be educated in interdisciplinary teams, there was a new focus on the importance of interdisciplinary education. Collaborative experiences in the humanities can foster professional relationships that lead to professional growth, promote collaboration, and enhance patient-centered care. The purpose of this article is to describe the relevance of humanities to the interdisciplinary education and practice of health care providers. This article extends the thinking about the value of interdisciplinary education beyond the traditional dimensions of evidence-based practice, quality improvement, and informatics to humanities. Ways to provide nurses and physicians with interdisciplinary humanistic experiences are illustrated through an overview of projects jointly developed by the School of Nursing and the College of Medicine at The Pennsylvania State University. (Index words: Humanities; Interdisciplinary; Physicians; Nursing)

Informal caregivers are responsible for providing the majority of post-discharge care for many frail older adults in rural settings. The purpose of this study was to investigate whether an advanced practice nurse (APN) intervention would promote more positive physical and emotional outcomes in caregivers of rural older adults who are frail and were recently discharged from urban-based hospitals. Thirty-two caregivers of frail rural elderly individuals were randomly assigned to treatment (APN intervention) and control groups (no APN intervention). Assessments of caregiver outcomes were collected via telephone interviews at 48-hour, 2-week, and 4-week intervals after hospital discharge of the frail rural older adults. Outcomes were operationalized as caregiver physical health and well being, and stress and burden. The former was measured using the Health and Daily Living form (HDL) and the latter by the Thoughts and Feelings and Time and Energy subscales of the Caregiver Burden Inventory (CBI). Additional information on caregiver problems and APN visit time was collected by the APN using the Omaha Classification System. Caregivers in the treatment group experienced significantly more positive physical and emotional health outcomes. The caregivers who received the APN intervention had higher self-rated emotional health scores, fewer emotional symptoms at Week 4, fewer depressive symptoms at Week 2 and 4, and lower Thoughts and Feelings stress scores at 48 hours than the control group. Findings support the importance of addressing the needs of caregivers post-discharge and the ability of APNs to improve post-discharge outcomes for home health care recipients and their caregivers.

This paper evaluates a novel nursing intervention designed to improve physical and psychological outcomes for adult patients with Type 2 DM.Self care behaviors are an important component of diabetes treatment, yet for many reasons, patients do not adhere to suggested plans. Motivational Interviewing (MI) is a patient centered strategy that helps overcome ambivalence to change. Nurses, who frequently educate patients with diabetes about self care, can use MI as a way to improve health behaviors.As a component of a large RCT, focus groups were used to evaluate the impact of an MI nursing intervention. Nineteen patients (8% of treatment group) participated in four different groups. IPA was used to explore patient response to the intervention.Patients were able to reflect on and identify responses to sessions with the study nurses that differed from "typical" health care provider visits. Many of their descriptions captured the essence of MI practice.MI is a viable and useful technique for nurses to use in educating and caring for persons with Type 2 DM.

After discharge from the hospital, older patients often require continued home care, including both professional and nonprofessional services. These needs can be exacerbated by health status (i.e., frailty) and geographic residence (i.e., rurality). It was the purpose of this study to examine patterns of postdischarge home care and outcomes for frail elders from rural locations. Seventy frail older adults being discharged from an acute urban-based hospital to home in a rural setting were recruited. Baseline data were collected before discharge from the hospital, and then calls were made at 48 hr and 2 and 4 weeks after discharge to evaluate use of resources and out-of-pocket expenses. Nonprofessional services were used most frequently, and the most intense time of use was at the 2-week postdischarge period. These findings suggest that discharge planning should include obtaining information about availability of both professional and nonprofessional services in the home community and arranging for appropriate delivery of both.

IMPLICATIONS FOR PRACTICE

The inability to efficiently screen the cognitive status of homebound elderly patients can hamper clinicians' ability to plan for safe, appropriate care. In this study, the six-item Orientation-Memory-Concentration (OMC) Test was administered to 12 elderly patients during a routine office visit. That same afternoon, each participant was called at home and the OMC repeated by telephone. Test-retest correlation was excellent (Pearson's correlation =.992). Concurrent validity was supported by complete (100%) agreement between the clinicians' subjective impressions of the patients' mental status and OMC ratings. The outcome implies that telephone screening of cognitive status can be reliable.

BACKGROUND: Numerous invasive, uncomfortable, and discomforting procedures are implemented almost routinely during trauma care. Previous research has shown that trauma care practitioners use comforting strategies during this care. Yet little is known of the effect of these comforting strategies on the effectiveness and efficiency of treatment. OBJECTIVES: To evaluate the effect of the caregiver's approach on the efficient and effective completion of a discomforting procedure (nasogastric tube insertion) on conscious patients during trauma care. METHODS: Ethology was used to analyze 32 attempts at nasogastric tube insertion from 193 videotaped trauma cases from 3 level I trauma centers in North America. Both qualitative and quantitative analytic techniques were used. RESULTS: The practitioner's approach was associated with the outcome of the treatment. Overall, practitioners who balanced the technical aspects of the procedure with use of comforting strategies to minimize the patient's discomfort (the blended approach) were most efficient and most effective in completing this procedure. Practitioners who were most attentive to procedural technique (with little respect to patients' discomfort) or who were overly attentive to comforting strategies (termed the technical and affective approaches, respectively) took longer and/or were less successful at completing the procedure. CONCLUSIONS: Four patterned, standardized approaches to care were found: technical, affective, blended, and mixed. This study has implications for further research into the effect of the practitioner's approach on the patient's behavioral state in trauma care.

As advanced practitioners, clinical nurse specialists and nurse practitioners have a leadership role in integrating and promoting nursing research in clinical settings. In this quasi-experimental study, the role of the advanced practice nurse in developing and implementing an intervention that improved delirium screening by staff nurses is described. Screening practices of the treatment group nurses were accurate in 100% of the cases. Control nurses failed to detect any cases of delirium. A discussion of study findings and their relevance to advanced practice nursing are discussed.

Promoting application of study findings to the clinical setting is a constant challenge for nurse researchers. This project used change theory to include staff RNs in a research study on delirium and to use relevant findings. The research hypothesis was: Staff nurses who use a standardized protocol will have improved ability to identify delirium in elderly hospital patients. Staff nurses on the intervention unit used this protocol to screen for delirium on all consenting inpatients 75 years of age and over, and control unit nurses continued using their standard assessment practices. Intervention unit nurses demonstrated an improved ability to identify the presence and absence of delirium, and voluntarily requested to continue using the protocol after the study was terminated. Use of a theoretical model to include nurses in the study promoted the successful conduct of the research and subsequent use of findings.

Demographic trends indicate a growth in the older adult population, and in turn, are affecting the availability and use of health services. Although placement of an older adult charge into nursing home care is often described as a logical progression through the continuum of available services, informal caregivers often view placement as a last resort or as an indication of failure. This qualitative study used grounded theory methods to explore the experiences of caregivers actively involved in the process ofplacing an older adult in a long-term carefacility upon discharge from acute care. Four themes (uncertainty, surrendering to the system, urgency, and validating) were interwoven throughout caregivers'perspectives of the conflictive decision to use nursing home care after hospitalization.

IN THIS ARTICLE, how one home health agency developed services for a high-risk group of clients based on a research study conducted on-site is described. Part of that study compared the cost of home care for cognitively impaired and cognitively intact persons over the age of 65. Although care for older adults with cognitive impairment was less expensive in terms of actual dollars, hospital and agency readmissions were significantly greater for those who were cognitively impaired, which led to greater total costs. Study results document that cognitively impaired older adults have special home care needs. Results were used to develop a special psychogeriatric program within the home health agency where data were collected. A CNS is now the key feature of this program; the CNS role in addressing the special needs of cognitively impaired home health clients is outlined.

1. Hypercholesterolemia in the elderly is a major risk factor for cardiovascular disease. 2. Elderly subjects were found to be concerned about their cholesterol, but awareness of beneficial cholesterol reduction strategies and desirable cholesterol levels were low. 3. Major concerns for the rural elder are accessibility to cholesterol screening, explanation of the results of screening, and education about dietary interventions. 4. Nurses developing health promotion programs for rural elders need to incorporate methods which promote accessibility to screening and follow-up, understandable written information, and family support.

This qualitative study was conducted to examine the decision-making process and its immediate consequences forfamily members who placed an elderly loved one in a long-term care facility. To explore issues related to the placement process, in-depth interviews were conducted with 7 individuals who had recently (6 weeks or less) placed an older relative. Content analyses of the interviews were conducted, and several common themes related to the decision-making process and outcomes emerged. Most of the subjects hadprovided personal care for their elderly relative, so placing their loved one in a nursing home often conflicted with their view of themselves as an ideal caregiver During the process of making the decision, althoughfamily members were given advice and suggestions by health care professionals, this input was viewed as inadequate or even detrimental. Ultimately, subjects described making the decision to place an elderly relative in a long-term care facility as a singular process involving "I" rather than "we. " The positive and negative role of friends emerged as an important influence during and after the placement process. The informal validation of the decision to place by peers was the one interaction that family members identified as helpful during this process.

The aim of the present study was to determine whether the addition of nurse case managers (NCMs) trained in motivational interviewing (MI) to usual care would result in improved outcomes in high-risk type 2 diabetes patients.A 2-year randomized controlled pragmatic trial randomized 545 patients to usual care control (n=313) or those who received the intervention (n=232) with additional practice-embedded NCM care, including MI-guided behavior change counseling. The NCMs received intensive MI training with ongoing fidelity assessment.Systolic blood pressure (SBP) was better in the intervention than usual care group (131 ± 15 vs. 135 ± 18 mmHg, respectively; P0.05). Improvements were seen in both the control and intervention groups in terms of HbA1c (from 9.1% to 8.0% and from 8.8% to 7.8%, respectively), low-density lipoprotein (LDL; from 127 to 100 mg/dL and from 128 to 102 mg/dL, respectively), and diastolic blood pressure (from 78 to 74 mmHg and from 80 to 74 mmHg, respectively). Depression symptom scores were better in the intervention group. The reduction in diabetes-related distress approached statistical significance.The NCMs and MI improved SBP and complications screening. The large decrease in HbA1C and LDL in the control group may have obscured any further intervention effect. Although nurses prompted providers for medication titration, strategies to reduce provider clinical inertia may also be needed.

Home health nursing practice requires the ability to accurately assess elderly clients and, based on this assessment, arrange for needed home care services. Accurate evaluation of a homebound elder's mental status is particularly important, for it indicates whether the individual will be able to survive in his or her home and thereby avoid institutionalization. However, previous studies suggest that nurses in a variety of settings use assessment criteria that result in inaccurate judgements about their client's cognitive status. This study was undertaken to investigate specific strategies used by home health nurses to determine mental status. A convenience sample of 84 home health nurses was surveyed about the assessment criteria they used in their practice. Findings showed that these nurses, like others, rely primarily on orientation to evaluate cognition.

Individuals with cognitive impairment are at high risk for institutionalization; thus, they may benefit from the support provided by home health services. The authors studied a cohort of elderly persons admitted to a home health agency, after first assessing them for cognitive impairment. Comparisons were made between cognitively impaired and cognitively intact individuals. Significant differences in the volume and type of services used were found. Management issues for home health agencies are raised.

Cognitive impairment is a serious and pervasive problem for ill elderly uersons in the institutional setting. Older individuals exit these facilities quickly, often requiring continued formal health care services in their homes. The prevalence of delirium and/ or dementia in older, medically ill home health clients has not been investigated. It was the purpose of this descriptive study to systematically screen a sample of elderly admissions to a visiting nurse association for cognitive impairment. One hundred individuals over the age of sixty-five were given the Mini-Mental State Exam (Folstein, Folstein & McHugh, 1975) on admission to lhe agency. Information on demographics and health status was retrieved from routine chart forms. Prevalence of imoairment was 61 %. Impaired individuals differed significantly from heir intact counterparts in relation to race, functional limitations, institutional length-of-stay and use of medications impacting on the central nervous &stem.

In both nursing practice and research settings, valid and accurate information on the cognitive function of elderly persons is necessary. However, methods and criteria for evaluating an elder's mental status are inconsistent. A formal screening tool such as the Mini Mental State Examination (MMSE) would enable nurse clinicians and researchers to use a common method for identifying cognitive impairment. In addition, the MMSE score can readily describe levels of impairment across settings. Although certain limitations exist when using this instrument, the MMSE has been successfully employed by some nurses in selected clinical and research settings as a brief but accurate screen of cognition in older persons.

Although the detrimental effects of divorce on the immediate family have been studied extensively, few researchers have focused on how extended family members such as grandparents respond. This ex post facto study was a preliminary investigation of how 47 grandparents felt about their relationship with grandchildren whose parents had divorced. Chi-square analysis of study data revealed that these grandparents perceived a significant decline in the quality of their relationship with grandchildren. The quality of these grandparent-grandchild relationships was influenced by custodial arrangements but not geographic distance. Implications for pediatric nursing are discussed.

Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample.To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance.Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined.Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance.Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.

Assessments of mental status in elderly persons admitted to home health agencies are the basis for decision-making related to resources provided. A home health nurse's perceptions of an elderly client's capacity for self-care determines whether community services will be prescribed. In institutional settings, evaluation of cognition by professional nurses is often incomplete or inaccurate. It was the purpose of this study to compare the judgements of cognition made by nine home health nurses who were admitting elderly clients to a visiting nurse association with scores from an objective measure of mental status. Findings suggest that these nurses relied primarily on orientation as an indicator of cognitive abilities.

The orientation period creates a context for nurses' relationships with their employers, and can adversely affect attrition rates. Although the orientation needs of novice nurses have been detailed, little is known about what might help those with prior experience. Hence, the goal of this study was to explore whether the orientation needs of seasoned nurses are similar to or unique from those of novice nurses. During a 6-month period, the authors used two intensive qualitative methodologies (daily journaling and focus groups) to study three experienced nurses. A tri-phased model of orientation emerged, with learning and support issues unique to experienced nurses identified. Results suggest that orientation programs for experienced nurses should use specific educational strategies and content to promote engagement in a new position. J Contin Educ Nurs 2009;40(7):311–316.

Despite evidence that diabetes is costly and devastating, the health care system is poorly equipped to meet the challenges of chronic disease care. The Penn State Institute of DiabetesObesity is evaluating a model of managing type 2 DM which includes nurse case management (NCM) and motivational interviewing (MI) to foster behavior change. The primary care intervention is designed to improve patients' self care and to reduce clinical inertia through provider use of standardized clinical guidelines to achieve better diabetes outcomes.This RCT tests the efficacy of an enhanced NCM intervention on type 2 DM (n=549) patient outcomes mediated by changes in self-care behavior and diabetes management. Outcome measures include: (a) effect on clinical parameters such as HbA1c (7), BP (130/80), and LDL (100), depression scores and weight; (b) process measures such as complication screening; (c) patient psychological and behavioral outcomes as measured by emotional distress (PAID), diabetes-specific quality of life (ADDQoL), patient satisfaction (DTSQ), self-care activities (SDSCA); and (d) physician satisfaction and cost-effectiveness of the intervention.Baseline includes (mean) age=58; BMI=34.4; 57% females; 47% Caucasian, and 39% Hispanic. Patients had elevated HbA1c (8.4), BP (137/77) and LDL (114). Overall, patients were depressed (CES-D=21.6) and had an extremely negative quality of life (ADDQoL=-1.58). We believe that enhanced NCM will both improve self-care and reduce emotional distress for patients with diabetes. If proven effective, enhanced NCM may be translated to other chronic illnesses.