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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.

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.

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.

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

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: 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

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.

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.

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.

Tight glucose control can significantly improve outcomes of critically ill geriatric patients in the critical care unit (CCU). In the past, blood glucose levels were managed by a point-of-care testing every 4 to 6 hours and using a sliding scale of insulin therapy. This article explores the need for more intensive intravenous insulin therapies. Studies have shown that patient outcomes improve by having a specific set of standing orders, a well-defined algorithm, and empowering the CCU nurses with these tools. Methods for initiating intensive intravenous insulin therapies are discussed along with some of the biggest challenges faced by CCU nurses at the bedside.

Background. After discharge from an acute care setting, elderly cardiac patients take a variety of medications in the home setting. Their pharmacologic regimens are often quite complex, and may involve drugs from several therapeutic categories. Patterns of medication use can be one measure of patient status after discharge because they can indicate whether medical conditions are stabilized. A problem related to medications during the postdischarge period is residence of the patient. For persons discharged to rural settings, access to health care resources and follow-up monitoring of medications may be problematic.Methods. This longitudinal study followed postdischarge medication use over a 5-month period. Thirty-two elderly persons admitted to a large tertiary care center for treatment of cardiac conditions were recruited. Baseline information was collected on demographics and health status, and subjects were then interviewed by telephone at 2, 4, 12, and 20 weeks postdischarge. Analysis of functional health complaints assessed by the Medical Outcomes Short Form (SF-36) and cardiac symptom scores were correlated with new and standing prescriptions over time and across geographic locations. Potential confounders such as age, gender, and severity of illness were controlled for.Results. Statistical analyses on continuity of medication use and changes in the category of medication prescribed revealed that urban subjects were prescribed more drugs and experienced significantly more alterations in their drug regimens.Conclusions. Contrary to expectations, urban subjects appeared to do worse over the postdischarge period with greater drug utilization that directly predicted the number of hospital readmissions and number of emergency room visits, even though their severity of illness was no different from their rural counterparts at the time of discharge.