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Background: Chronic stress causes harmful physiological responses that yield increased inflammation and subsequent health conditions. Stress is an important measure among minoritized populations who face social situations that predispose risk to developing mental health problems. Hair and fingernail cortisol have been studied as retrospective measures of chronic stress and to demonstrate biological response to social situations., Objectives: The objective of this study was to compare the Perceived Stress Scale (PSS) with hair and nail cortisol concentrations and assess the risk factors associated with stress levels among heterosexual and sexual and gender-minoritized adolescent males., Methods: We recruited a cohort of adolescents who were assigned male sex at birth. Approximately half of our cohort consisted of sexual and gender-minoritized people, and half consisted of heterosexual cisgender males. Participants provided hair and nail samples and completed a survey that included demographic and hair hygiene questions and the PSS. Hair and nail samples were processed in a laboratory, and survey results were analyzed descriptively., Results: Several samples were not provided or received, and some survey data were missing. Hair and nail cortisol values were significantly associated. There was no significant relationship between the PSS and hair and nail cortisol values. No significant differences were found between the heterosexual and sexual minoritized groups. Black participants reported lower perceived stress scores compared to White participants. Participants whose gender was nonbinary or genderqueer had higher hair cortisol values compared to those who identified as male. Older participants had higher hair cortisol values compared to younger participants., Discussion: Previous researchers have similarly found no correlation between self-report stress scales and cortisol values, increased stress experience among nonbinary or genderqueer individuals compared to cisgender individuals, and a positive correlation between aging and stress. Yet, our finding that Black participants reported lower stress levels than White participants is unexpected. Our study demonstrates a high correlation between hair and nail cortisol values, suggesting the potential to substitute these markers as needed., Competing Interests: The authors have no conflicts of interest to report., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Hair and nail cortisol is increasingly studied as a physiologic proxy for chronic stress response. Glucocorticoid use is an expected confounder for cortisol measurement, yet there remains little evidence of whether external cortisol use should be subject to exclusion in study subjects. In a group of 209 youth (15-22 year-olds), we analyzed hair and fingernail cortisol concentrations. We assessed topical, nasal, oral, and injectable glucocorticoid use via a questionnaire. Extensively validated methods were used for hair and nail cortisol extraction and measurements. The median value of hair cortisol was 10.2 pg/mg (n=200), and the median value of nail cortisol was 7.06 pg/mg (n=203). Topical glucocorticoid use significantly increased hair and nail cortisol concentrations (p<0.005). Hair and nail cortisol concentrations were positively associated (p<0.0001, n=194). Spearman correlation coefficients demonstrated that the positive correlation between hair and nail cortisol values was higher in participants who used external glucocorticoids. Topical glucocorticoids moderated the association between hair and nail cortisol values (p=0.006). Based on these findings, we recommend that the assessment of topical glucocorticoid use must be performed when collecting hair/nail samples and that subjects reporting glucocorticoid use should be excluded from all future hair and nail cortisol studies; also, all outliers must be excluded to account for glucocorticoid medication underreporting and yet-unknown confounders., Competing Interests: Declaration of Competing Interest All authors declare no conflict of interest. KB declares a significant financial interest in Stress Bioanalytics, LLC, which currently performs HCC and NCC measurements in numerous projects. The present work was completed a year before the creation of Stress Bioanalytics LLC., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction: Nurses are identified as having higher work stress and poor mental health risk among health care workforce globally. It remains unclear which modifiable stress factors pose the greatest risk for poor psychological health among nursing workforce and needed to inform targeted practice and policy change. To determine which occupation-related or personal stress factors precipitate higher risk for burnout, depression, anxiety, job satisfaction or intention to leave one's position among nurses globally., Design: A cross-sectional anonymous survey was administered via email using a snowball recruitment strategy., Methods: Academic researchers and clinical industry leaders across 3 global regions collaborated to generate an email listserv of professional nursing contacts for survey distribution. The survey included valid and reliable measures to scale stress factors (Work Stress Questionnaire), and screen for burnout (single item), depression (Patient Health Questionnaire-2), anxiety (Generalized Anxiety Disorder-2), resilience (Brief Resilience Scale) and intention to leave one's job (single item). We used logistic regression, first unadjusted and then adjusted for personal and professional characteristics, to determine associations between stress factors and psychological health risk., Results: The final sample consisted of responses from 2864 nurses working across 13 countries. Most respondents reported working as a clinical nurse in the Philippines (n = 2275), United States (n = 424) and Saudi Arabia (n = 104). One third of nursing respondents endorsed high burnout and intention to leave their job. Those reporting work conflict had significantly higher odds of burnout (odds ratio 3.18; 95% CI 2.22-4.54) and three times more likely to screen positive for depression (odds ratio 3.02; 95% CI 1.36-6.72) and anxiety (odds ratio 2.92; 95% CI 1.57-5.43). Those endorsing difficulty sleeping were 15 times more likely to screen positive for depression (odds ratio 15.63; 95% CI 2.09-117.06). Lack of social support was significantly associated to higher risk for burnout, job dissatisfaction, depression, anxiety, and intention to leave one's position., Conclusions: Nurses remain at risk for burnout and poor psychological health stemming from work stress. Factors such as clear workplace goals and assignments, increased engagement, good sleep health and social support may serve as protective factors against suboptimal psychological health, and in-turn poor workforce retention., Clinical Relevance: Nurses reporting conflict in the workplace are three times more likely to screen positive for burnout, depression, and anxiety. Nurses reporting difficulty sleeping are 15 times more likely to screen positive for depression. Several modifiable factors can be targeted to reduce poor psychological health and high workforce turnover among nurses across countries., (© 2024 Sigma Theta Tau International.)

Background: Survey-driven research is a reliable method for large-scale data collection. Investigators incorporating mixed-mode survey designs report benefits for survey research including greater engagement, improved survey access, and higher response rate. Mix-mode survey designs combine 2 or more modes for data collection including web, phone, face-to-face, and mail. Types of mixed-mode survey designs include simultaneous (ie, concurrent), sequential, delayed concurrent, and adaptive. This paper describes a research protocol using mixed-mode survey designs to explore health IT (HIT) maturity and care environments reported by administrators and nurse practitioners (NPs), respectively, in US nursing homes (NHs)., Objective: The aim of this study is to describe a research protocol using mixed-mode survey designs in research using 2 survey tools to explore HIT maturity and NP care environments in US NHs., Methods: We are conducting a national survey of 1400 NH administrators and NPs. Two data sets (ie, Care Compare and IQVIA) were used to identify eligible facilities at random. The protocol incorporates 2 surveys to explore how HIT maturity (survey 1 collected by administrators) impacts care environments where NPs work (survey 2 collected by NPs). Higher HIT maturity collected by administrators indicates greater IT capabilities, use, and integration in resident care, clinical support, and administrative activities. The NP care environment survey measures relationships, independent practice, resource availability, and visibility. The research team conducted 3 iterative focus groups, including 14 clinicians (NP and NH experts) and recruiters from 2 national survey teams experienced with these populations to achieve consensus on which mixed-mode designs to use. During focus groups we identified the pros and cons of using mixed-mode designs in these settings. We determined that 2 mixed-mode designs with regular follow-up calls (Delayed Concurrent Mode and Sequential Mode) is effective for recruiting NH administrators while a concurrent mixed-mode design is best to recruit NPs., Results: Participant recruitment for the project began in June 2023. As of April 22, 2024, a total of 98 HIT maturity surveys and 81 NP surveys have been returned. Recruitment of NH administrators and NPs is anticipated through July 2025. About 71% of the HIT maturity surveys have been submitted using the electronic link and 23% were submitted after a QR code was sent to the administrator. Approximately 95% of the NP surveys were returned with electronic survey links., Conclusions: Pros of mixed-mode designs for NH research identified by the team were that delayed concurrent, concurrent, and sequential mixed-mode methods of delivering surveys to potential participants save on recruitment time compared to single mode delivery methods. One disadvantage of single-mode strategies is decreased versatility and adaptability to different organizational capabilities (eg, access to email and firewalls), which could reduce response rates., International Registered Report Identifier (irrid): DERR1-10.2196/56170., (©Gregory L Alexander, Lusine Poghosyan, Yihong Zhao, Mollie Hobensack, Sergey Kisselev, Allison A Norful, John McHugh, Keely Wise, M Brooke Schrimpf, Ann Kolanowski, Tamanna Bhatia, Sabrina Tasnova. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 29.08.2024.)

Moral distress and moral injury among health workers yield adverse physical, psychological, and labor force outcomes. Research is limited on how psychiatric healthcare assistants experience these issues. In this multi-method study, we conducted a quantitative survey and qualitative interviews to examine moral distress and injury among psychiatric healthcare assistants. Almost half screened positive for moral injury. Three qualitative themes emerged: 1) hierarchies prevent contributions to care; 2) trust as a factor in de-escalating patient violence; and 3) navigating psychosocial challenges. Further research is recommended to investigate how to best support and inform practice and policy changes for psychiatric healthcare assistants., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objective: Research study complexity refers to variables that contribute to the difficulty of a clinical trial or study. This includes variables such as intervention type, design, sample, and data management. High complexity often requires more resources, advanced planning, and specialized expertise to execute studies effectively. However, there are limited instruments that scale study complexity across research designs. The purpose of this study was to develop and establish initial psychometric properties of an instrument that scales research study complexity., Methods: Technical and grammatical principles were followed to produce clear, concise items using language familiar to researchers. Items underwent face, content, and cognitive validity testing through quantitative surveys and qualitative interviews. Content validity indices were calculated, and iterative scale revision was performed. The instrument underwent pilot testing using 2 exemplar protocols, asking participants ( n = 31) to score 25 items (e.g., study arms, data collection procedures)., Results: The instrument (Research Complexity Index) demonstrated face, content, and cognitive validity. Item mean and standard deviation ranged from 1.0 to 2.75 (Protocol 1) and 1.31 to 2.86 (Protocol 2). Corrected item-total correlations ranged from .030 to .618. Eight elements appear to be under correlated to other elements. Cronbach's alpha was 0.586 (Protocol 1) and 0.764 (Protocol 2). Inter-rater reliability was fair (kappa = 0.338)., Conclusion: Initial pilot testing demonstrates face, content, and cognitive validity, moderate internal consistency reliability and fair inter-rater reliability. Further refinement of the instrument may increase reliability thus providing a comprehensive method to assess study complexity and related resource quantification (e.g., staffing requirements)., Competing Interests: None., (© The Author(s) 2024.)

Background: Co-management encompasses the dyadic process between two healthcare providers. The Provider Co-Management Index (PCMI) was initially developed as a 20-item instrument across three theory-informed subscales., Objective: This study aimed to establish construct validity of the PCMI with a sample of primary care providers through exploratory and confirmatory factor analyses., Methods: We conducted a cross-sectional survey of primary care physicians, nurse practitioners, and physician assistants randomly selected from the IQVIA database across New York State. Mail surveys were used to acquire a minimum of 300 responses for split sample factor analyses. The first subsample (derivation sample) was used to explore factorial structure by conducting an exploratory factor analysis. A second (validation) sample was used to confirm the emerged factorial structure using confirmatory factor analysis. We performed iterative analysis and calculated good fit indices to determine the best-fit model., Results: There were 333 responses included in the analysis. Cronbach's alpha was high for a three-item per dimension scale within a one-factor model. The instrument was named PCMI-9 to indicate the shorter version length., Discussion: This study established the construct validity of an instrument that scales the co-management of patients by two providers. The final instrument includes nine items on a single factor using a 4-point, Likert-type scale. Additional research is needed to establish discriminant validity., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Healthcare worker retention and burnout are confounding issues. Trust among workers and their employer, that is, organization, is an important yet underexplored concept in research., Research Aim: The aim of this qualitative study is to explore organizational actions and systems that promote or denigrate trust among registered nurses and patient care aides (aides)., Research Design: The study uses the Model of Psychological Contract as a theoretical framework. Focus groups were conducted to explore the concept of organizational trust and the consequences of broken trust., Participants: Registered nurses (RNs) (n=6) and aides (n=6) participated in the study. Six focus groups (three RN and three aide) were conducted, with two participants per group. Focus groups were conducted online., Ethical Considerations: The study's methods were reviewed by the University of Pittsburgh Institutional Review Board., Findings: Among RNs and aides, a sense of trust and feeling valued were important to their sense of relationship with their employers. Trust was breached when resources were scarce, employees did not feel validated and listened to, and problems were not addressed. RNs and aides described feeling devalued when compensation practices were unjust or inequitable, they had limited autonomy, and the employer created an organizational climate where business needs superceded human caring. Consequences of trust breach included burnout, dejection, and feelings of non-belonging., Discussion: Tangible organizational resources (compensation and staffing) and intangible resources (value, respect, autonomy) are important to RNs and aides alike. Inability to provide these resources diminishes trust and even causes a sense of betrayal., Conclusion: Future research can explore the concepts of organizational justice and interventions to restore lost trust and improve healthcare worker well-being. This is one of only a few identified studies to explore organizational factors and well-being among aides and more research among this healthcare worker population is warranted., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Increasing evidence suggests that clinician well-being influences patient, workforce, and organizational outcomes. Despite increasing attention to well-being among licensed clinicians (e.g., nurses and physicians), collective evidence about well-being among healthcare assistants, such as nursing and medical assistants, is limited. Healthcare assistants make up a substantial portion of the clinical workforce delivering direct patient care. The well-being of healthcare assistants is critical to ensure an ample workforce supply. The objective of this systematic review was to contribute a reproducible search, summary, appraisal, synthesis, and critique of the literature about well-being among healthcare assistants, including factors that induce or inhibit burnout, and to identify gaps in evidence that warrant future research., Methods: We performed a literature search across 4 databases with keywords using BOOLEAN operators. After an initial title and abstract screen, a search of relevant reference lists, and full text review was peformed independently by 2 researchers. Study quality was evaluated using Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies. We extracted study characteristics, results, and deductively analyzed each study's alignment with the United States National Academy of Medicine's Clinician Well-Being Model., Results: We identified 28 articles meeting our inclusion criteria. Our synthesis indicated that most studies investigated personal factors (e.g., financial stressors or physical, emotional, and spiritual health) as opposed to organizational or policy factors (e.g., occupational policies or workplace culture) that may impact well-being. Younger workers and those with fewer years of experience appear to have higher burnout risk. Sleep health, improved unit-based culture (respect and increased decision-making with nurses), shorter shifts, and increased social support appear to be the most protective against burnout., Discussion: There remains a scarcity of evidence about factors impacting well-being among healthcare assistants. Existing literature focuses on individual, as opposed to external or organizational, contributory factors to burnout or well-being risk. Future studies should use specific methods to define and measure healthcare assistant roles, isolate harmful individual and organizational factors, and measure more specific sub-concepts of well-being such as depression. Such studies can contribute greatly to the overall understanding of healthcare assistant health and wellness, which subsequently may promote optimal patient and organizational outcomes., Tweetable Abstract: The hidden workforce: Systematic review demonstrates gaps in evidence about wellbeing and burnout among healthcare assistants and aides., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Team-based care has become a cornerstone of care delivery to meet the demands of high-quality patient care. Yet, there is a lack of valid and reliable instruments to measure the effectiveness of co-management between clinician dyads, particularly physicians and registered nurses (RNs). The purpose of this study was to adapt an existing instrument, Provider Co-Management Index (PCMI), previously used among primary care providers into a new version to scale RN-physician co-management (called PCMI-RN). We also aimed to explore preliminary associations between RN-physician co-management and burnout, job satisfaction, and intention to leave current job. Face, cognitive, and content validity testing, using mixed methods approaches, were preceded by initial pilot testing ( n  = 122 physicians and nurses) in an acute care facility. The internal consistency reliability ( α =.83) was high. One-quarter of participants reported burnout, 27% were dissatisfied with their job, and 20% reported intention to leave their job. There was a weak significant correlation between co-management and burnout ( p  = .010), and co-management and job satisfaction ( p  = .009), but not intention to leave current position. Construct validity testing is recommended. Future research using PCMI-RN may help to isolate factors that support or inhibit effective physician-nurse co-management.

Background: Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses' experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts., Research Aim: To analyze frontline U.S. nurses' experiences of ethics during the COVID-19 pandemic., Research Design: Qualitative analysis using a directed content methodology., Participants and Research Context: The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States., Ethical Considerations: Participant privacy and data confidentiality were addressed., Findings: Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients., Discussion: This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice., Conclusions: Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Few studies have examined emergency nurses who have left their job to better understand the reason behind job turnover. It also remains unclear whether emergency nurses differ from other nurses regarding burnout and job turnover reasons. Our study aimed to test differences in reasons for turnover or not currently working between emergency nurses and other nurses; and ascertain factors associated with burnout as a reason for turnover among emergency nurses., Methods: We conducted a secondary analysis of 2018 National Sample Survey for Registered Nurses data (weighted N = 3,004,589) from Health Resources and Services Administration. Data were analyzed using descriptive statistics, chi-square and t-test, and unadjusted and adjusted logistic regression applying design sampling weights., Results: There were no significant differences in burnout comparing emergency nurses with other nurses. Seven job turnover reasons were endorsed by emergency nurses and were significantly higher than other nurses: insufficient staffing (11.1%, 95% confidence interval [CI] 8.6-14.2, P = .01), physical demands (5.1%, 95% CI 3.4-7.6, P = .44), patient population (4.3%, 95% CI 2.9-6.3, P < .001), better pay elsewhere (11.5%, 95% CI 9-14.7, P < .001), career advancement/promotion (9.6%, 95% CI 7.0-13.2, P = .01), length of commute (5.1%, 95% CI 3.4-7.5, P = .01), and relocation (5%, 95% CI 3.6-7.0, P = .01). Increasing age and increased years since nursing licensure was associated with decreased odds of burnout., Discussion: Several modifiable factors appear associated with job turnover. Interventions and future research should account for unit-specific factors that may precipitate nursing job turnover., (Copyright © 2023 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to examine the effectiveness of a bedside checklist enforcing nursing-led interventions in hospitalized COVID-19 patients early in the pandemic., Background: The absence of treatment guidelines for COVID-19 presented challenges to reducing mortality rates early in the pandemic. A bedside checklist and a bundle of nursing-led interventions named "Nursing Back to Basics (NB2B)" were assembled for patient care after a scoping review of evidence., Methods: A retrospective analysis was conducted to investigate the impact of the evidence-based interventions randomly implemented based on patient bed assignment. Electronic data (patient demographics, bed assignment and ICU transfers, length of stay, and patient discharge disposition) were extracted and calculated using descriptive statistics, t tests, and linear regression., Results: Patients receiving the NB2B intervention enforced with a bedside checklist had significantly lower mortality rates (12.3%) compared with those receiving standard nursing care (26.9%)., Conclusions: Bedside checklists enforcing evidence-based nursing-led interventions may be beneficial as a 1st-line public health emergency response., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Marginalized groups experience a higher frequency of traumatic injury and are more likely to report negative experiences in the health care setting. Trauma center staff are prone to compassion fatigue, which impairs patient and clinician interactions for these groups. Forum theater (a form of interactive theater designed for addressing social issues) is proposed as an innovative method of exploring bias and has never been applied in the trauma setting., Objective: This article aims to determine the feasibility of implementing forum theater as an adjunct to enhance clinician understanding of bias and its influence on communication between clinicians and trauma populations., Methods: This is a descriptive qualitative analysis of adopting forum theater at a Level I trauma center in a New York City borough with a racially and ethnically diverse population. The implementation of a forum theater workshop was described, including our work with a theater company to address bias in the health care setting. Volunteer staff members and theater facilitators participated in an 8-hr workshop leading to a 2-hr multipart performance. Participant experiences were collected in a postsession debrief to understand the utility of forum theater., Results: Debriefing sessions after forum theater performances demonstrated that forum theater is a more engaging and effective method for dialogue surrounding bias than personal past experiences with other educational models., Conclusion: Forum theater was feasible as a tool to enhance cultural competency and bias training. Future research will examine the impact it has on levels of staff empathy and its impact on participants' level of comfort communicating with diverse trauma populations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Society of Trauma Nurses.)

Frontline clinicians responding to the COVID-19 pandemic are at increased risk of burnout, but less is known about the trajectory of clinician burnout as caseloads increase and decrease. Personal and professional resources, including self-efficacy and hospital support, can attenuate the risk of burnout. Yet, empirical data documenting how burnout and resources changed as the pandemic waxed and waned are limited. This intensive longitudinal prospective study employed ecological momentary assessment methods to examine trajectories of burnout and resources over the pandemic's first year in a New York City hospital. A 10-item survey was emailed every 5 days to frontline clinicians (physicians, nurses, and physician assistants). The primary outcome was a single-item validated measure of burnout; predictors included daily hospital COVID-19-related caseloads and personal and professional resources. Clinicians ( n = 398) completed the initial survey and an average of 12 surveys over the year. Initially, 45.3% of staff reported burnout; over the year, 58.7% reported burnout. Following the initial COVID peak, caseloads declined, and burnout levels declined. During the second wave of COVID, as caseloads increased and remained elevated and personal and professional resource levels decreased, burnout increased. This novel application of intensive longitudinal assessment enabled ongoing surveillance of burnout and permitted us to evaluate how fluctuations in caseload intensity and personal and professional resources related to burnout over time. The surveillance data support the need for intensified resource allocation during prolonged pandemics.

Introduction: The purpose of this qualitative study was to synthesize frontline U.S. nursing perspectives about the current state of U.S. public health emergency preparedness and response. The study findings may inform public health policy change and improve future national pandemic planning and responses., Design: We conducted a secondary thematic qualitative analysis using grounded theory methodology., Methods: Data collection occurred through semi-structured, in-depth focus groups between July and December 2020, from 43 frontline nurses working in hospitals in four states (Ohio, California, Pennsylvania, and New York). Data were analyzed deductively, aligned with Khan et al.'s Public Health Emergency Preparedness Framework and inductively for emergent themes., Results: Three themes emerged: (1) Validation of the presence of health disparities and inequities across populations; (2) Perceived lack of consistency and coordination of messaging about pandemic policies and plans across all levels; and (3) challenges securing and allocating nursing workforce resources to areas of need., Conclusion: From a frontline nursing perspective, this study demonstrates the critical need to address health inequities and inequalities across populations, a consistent national vehicle for communication, and national plan for securing and allocating nursing workforce resources., (© 2022 Sigma Theta Tau International.)

The COVID-19 pandemic altered work environments of nurses, yielding high rates of stress and burnout. Potential protective factors, including effective sleep, may influence psychological health and wellbeing. Evidence about sleep in nurses may help develop interventions that mitigate burnout and poor psychological outcomes. A cross sectional survey was distributed across three hospitals to nurses in New York City (NYC). During the first wave of the pandemic (March-April 2020), NYC had the highest incidence of laboratory-confirmed COVID-19 cases (915/100 000) and half of all COVID-related deaths nationwide. Multivariable logistic regression was used to determine associations between Pittsburgh Sleep Quality Index (PSQI) global sleep score, PSQI sleep dimensions, and psychological health (burnout, depression, anxiety, and compassion fatigue), unadjusted and then controlling for individual and professional characteristics. More than half of the participants reported burnout (64%), depression, (67%), and anxiety (77%). Eighty percent of participants had PSQI global scores >5 (poor sleep) (mean 9.27, SD 4.14). Respondents reporting good sleep (PSQI ≤ 5) had over five times the odds of no burnout (OR: 5.65, 95% CI: 2.60, 12.27); increased odds of screening negative for depression (OR: 6.91, 95% CI: 3.24, 14.72), anxiety (OR: 10.75, 95% CI: 4.22, 27.42), and compassion fatigue (OR: 7.88, 95% CI: 1.97, 31.51). Poor subjective sleep quality PSQI subcomponent was associated with burnout (OR: 2.21, 95% CI: 1.41, 3.48) but sleep duration subcomponent was not (OR: 0.84, 95% CI: 0.59, 1.19). Daytime dysfunction was significantly associated with all psychological outcomes. Sleep disturbances and medications yielded higher anxiety odds. Overall, sleep quality appears more strongly related to burnout than sleep duration in nurses working during the COVID-19 pandemic. Sleep interventions should target individual sleep dimensions in nurses., (© The Author(s) 2022. Published by Oxford University Press on behalf of Sleep Research Society.)

Background: Family practice registered nurses co-managing patient care as healthcare professionals in interdisciplinary primary care teams have been shown to improve access, continuity of care, patient satisfaction, and clinical outcomes for patients with chronic diseases while being cost-effective. Currently, however, it is unclear how different funding models support or hinder the integration of family practice nurses into existing primary health care systems and interdisciplinary practices. This has resulted in the underutilisation of family practice nurses in contributing to high-quality patient care., Methods: This mixed-methods project is comprised of three studies: (1) a funding model analysis; (2) case studies; and (3) an online survey with family practice nurses. The funding model analysis will employ policy scans to identify, describe, and compare the various funding models used in Canada to integrate family practice nurses in primary care. Case studies involving qualitative interviews with clinic teams (family practice nurses, physicians, and administrators) and family practice nurse activity logs will explore the variation of nursing professional practice, training, skill set, and team functioning in British Columbia, Nova Scotia, Ontario, and Quebec. Interview transcripts will be analysed thematically and comparisons will be made across funding models. Activity log responses will be analysed to represent nurses' time spent on independent, dependent, interdependent, or non-nursing work in each funding model. Finally, a cross-sectional online survey of family practice nurses in Canada will examine the relationships between funding models, nursing professional practice, training, skill set, team functioning, and patient care co-management in primary care. We will employ bivariate tests and multivariable regression to examine these relationships in the survey results., Discussion: This project aims to address a gap in the literature on funding models for family practice nurses. In particular, findings will support provincial and territorial governments in structuring funding models that optimise the roles of family practice nurses while establishing evidence about the benefits of interdisciplinary team-based care. Overall, the findings may contribute to the integration and optimisation of family practice nursing within primary health care, to the benefit of patients, primary healthcare providers, and health care systems nationally., (© 2022. The Author(s).)

Objective: Asthma is a common chronic illness affecting 19 million US adults. Inhaled corticosteroids are a safe and effective treatment for asthma, yet, medication adherence among patients remains poor. Shared decision-making, a patient activation strategy, can improve patient adherence to inhaled corticosteroids. This study aimed to explore whether audio-recorded patient-primary care provider encounters can be used to: 1. Evaluate the level of patient-perceived shared decision-making during the encounter, and 2. Predict levels of patient's inhaled corticosteroid adherence., Materials and Methods: Shared decision-making and inhaled corticosteroid adherence were assessed using the SDM Questionnaire-9 and the Medication Adherence Report Scale for Asthma (MARS-A). Speech-to-text algorithms were used to automatically transcribe 80 audio-recorded encounters between primary care providers and asthmatic patients. Machine learning algorithms (Naive Bayes, Support Vector Machines, Decision Tree) were applied to achieve the study's predictive goals., Results: The accuracy of automated speech-to-text transcription was relatively high (ROUGE F-score = .9). Machine learning algorithms achieved good predictive performance for shared decision-making (the highest F-score = .88 for the Naive Bayes) and inhaled corticosteroid adherence (the highest F-score = .87 for the Support Vector Machines)., Discussion: This was the first study that trained machine learning algorithms on a dataset of audio-recorded patient-primary care provider encounters to successfully evaluate the quality of SDM and predict patient inhaled corticosteroid adherence., Conclusion: Machine learning approaches can help primary care providers identify patients at risk for poor medication adherence and evaluate the quality of care by measuring levels of shared decision-making. Further work should explore the replicability of our results in larger samples and additional health domains., Competing Interests: The authors have declared that no competing interests exist.

Objective: The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic., Background: The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored., Design: A qualitative study design was used., Methods: Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study., Results: The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping., Conclusions: Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses., Relevance to Clinical Practice: Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions., (© 2021 John Wiley & Sons Ltd.)

Background: Effective team communication is an essential aspect of care delivery and the coordination of patients in primary care settings. With the rapid evolution of health information technology (HIT), including the implementation of electronic health records, there remains a gap in the literature about preferred methods of primary care team communication and the subsequent impact of provider and team outcomes (e.g., team cohesiveness; burnout). This study explores the impact of varying modes of communication across provider disciplines and by geographic settings during primary care delivery., Methods: We used a cross-sectional survey design to collect data from a random convenience sample of PCPs (physicians, nurse practitioners, and physician assistants) ( n  = 314) in New York State (NYS). We mailed a paper survey with validated measures for communication methods, team cohesiveness, and provider outcomes (burnout, job dissatisfaction, and the intention to leave position). Descriptive statistics, linear regression models, and crude and adjusted odds ratios while controlling for individual and practice characteristics were calculated., Results: In-person communication was found to yield greater job satisfaction and less intention to leave current position in the next year ( p =0.02) compared to other forms of communication including electronic health record features. The odds of job satisfaction was 1.51 times higher with in-person communication (OR: 1.51, 95% CI: 1.05, 2.19), and the odds of intending to leave a position was 45% less with in-person communication (OR: 0.55, 95% CI: 0.36, 0.85). The odds of reporting burnout at work was 36% less with in-person communication (OR: 0.64, 95% CI: 0.43, 0.92) compared to other communication modalities. There was no significant association between team communication via the EHR and team cohesiveness, provider burnout, or job satisfaction., Conclusion: This study demonstrates evidence that in-person communication is more likely to reduce burnout and job dissatisfaction compared to other forms of communication infrastructure in primary care settings. More research is needed to understand PCP perspectives about the functionality and potential burden that inhibits the use of EHR features for provider-provider communication. In addition, attention to the needs of teams by geographic location and by workforce discipline is warranted to ensure effective HIT communication application adoption., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2022 Allison A. Norful et al.)

Background: Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care., Methods: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies., Results: Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care., Conclusions: This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care., Protocol Registration Id: PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 ., (© 2022. The Author(s).)

Rationale, Aims and Objectives: Increased incidence of chronic illnesses coupled with physician shortages have yielded strain on primary care provider (PCP) to meet care demands. Interdisciplinary providers have increasingly been embedded into primary care teams to alleviate some workload demand. Little evidence exists about the impact of interdisciplinary PCP care delivery models on provider strain in primary care. To determine the impact of interdisciplinary PCP care delivery on burnout, job satisfaction and intention to leave current position., Methods: We conducted a cross-sectional mail survey using Dillman methodology of primary care practices (e.g., internal medicine) across New York State. A random sample of interdisciplinary PCPs (physicians, nurse practitioners, and physician assistants) (n = 333) responded. The Provider Comanagement Index (α = 0.85) was used to measure how well interdisciplinary dyads comanagement care delivery attributes (effective communication; mutual respect and trust; shared philosophy of care). Provider outcomes were measured with validated Agency for Healthcare Research and Quality and Health Resources and Services Administration items for burnout, job satisfaction and intention to leave position. Descriptive statistics, logistic regression models, crude and adjusted odds ratios were calculated, controlling for participant and practice characteristics., Results: Almost 30% of participants reported burnout with three times the odds of intending to leave their current position within 1 year. With each unit increase in effective comanagement between interdisciplinary dyads there was 15% less burnout and 10% less odds of intention to leave position., Conclusion: Incorporating interdisciplinary specialties in primary care appears promising to alleviate some adverse provider outcomes. Organizations contemplating delivery models to promote well-being and retention may consider comanagement. Cost effectiveness research is needed to determine financial sustainability of interdisciplinary care delivery., (© 2021 John Wiley & Sons Ltd.)

Background: Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care., Methods: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken., Results: Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support)., Conclusions: The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs., Protocol Registration Id: PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 ., (© 2022. The Author(s).)

Background: Registered nurses have increasingly taken on new, integrated roles across a variety of health care settings, thus leading to a lack of clarity among titles used to identify registered nurses. Protected titles, such as "registered nurse," identify regulated professionals, whereas informal job titles identify nurses by their education or practice area. The variation in education requirements of registered nurses and the inconsistency in titles used to identify registered nurses in primary care internationally limits the ability to compare research findings and policies across countries. There is also minimal documentation on the education requirements specific to registered nurses in primary care., Objectives: This study aims to (a) outline protected titles and education requirements for registered nurses; and (b) identify job titles and education requirements specific to registered nurses in primary care internationally., Methods: A modified document analysis with key informant consultations was employed. Organization for Economic Co-operation and Development and key partner countries were considered for inclusion ( n =42). Online searches were performed using keywords (e.g. nurse, title, nursing education) to identify data focused on protected titles and education requirements of registered nurses, and job titles and education requirements of registered nurses in primary care. Data were extracted from online sources and verified for accuracy and completeness by key informants, identified for each country through online searches or professional networks., Results: Out of the 42 eligible countries, 24 countries were included in the final analysis. Five countries were excluded for their lack of available documents in English or French and 13 countries were excluded due to an inability to verify data with key informants. The findings show that "registered nurse" is the most common protected title internationally. Other protected titles include "general nurse" and "nurse." Many unofficial job titles for registered nurses in primary care were identified, including "primary care nurse," "general practice nurse," and "community nurse." Twelve countries had no specific job title for registered nurses in primary care. Consistently, there was no mandatory education required for registered nurses to practice in primary care. However, many countries had primary care-specific programs available for nurses to gain knowledge in this area., Conclusions: This study confirms that job titles used to identify registered nurses in primary care vary considerably across countries. A unified understanding of international nomenclature for this role can support and facilitate future research, education, and policy development to recognize and optimize primary care nursing by improving access and quality of care for individuals, families, and communities., Tweetable Abstract: Globally, job titles of RNs in primary care vary considerably and there are no formal primary care education requirements to practice., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors. Published by Elsevier Ltd.)

Background: Burnout threatens patient care and clinicians are experiencing challenges within the practice environment. Little is known about nurse practitioner (NP) perceptions of burnout and its relationship to care quality and practice environment. We investigate the relationship between primary care NP burnout on perceptions of care quality and if the practice environment moderates the relationship between burnout and care quality., Methods: This is a secondary analysis of cross-sectional survey data from 396 NPs. Burnout and care quality were measured using a single item, but the practice environment was measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire. Multi-level proportional odds cumulative logit models were built to test for associations between burnout and care quality and for moderation., Results: Total, 25.3% of NPs reported burnout. Odds of perceiving higher quality of care was 85% less for NPs experiencing burnout compared to those not experiencing burnout. Practice environment did not moderate the relationship between burnout and care quality, but with a one unit increase in the practice environment subscales, the odds of NPs perceiving higher care quality increased anywhere from 3.83 to 7.57 times., Conclusion: Burnout is related to lower perceptions of care quality but favorable environments were related to higher perceptions of quality., (© 2021 Wiley Periodicals LLC.)

Over 43 million Americans are diagnosed with a mental illness. Various factors, including health professionals' attitudes, prevent patients from seeking care. Previous evidence fails to identify nursing staff attitudes toward patients with mental illness. This cross-sectional study investigated attitudes toward mental illness of 146 registered nurses and mental health technicians in a psychiatric hospital. The study was guided by the Modified Labeling Theory. Respondents expressed stereotyping beliefs that people with mental illness would be devaluated and discriminated, and endorsed stigmatizing attitudes expressing stronger desire for social distance from a person with schizophrenia than depression or diabetes. Implications for future research, nursing education and practice are discussed.

Background: Little is known about clinical staff's perspectives on preparedness for a pandemic. The purpose of this study was to obtain various clinical staff perspectives about preparedness to meet the demands for care during the early phase of the SARS-CoV-2 (COVID-19) pandemic., Methods: We conducted a qualitative study using semistructured in-person interviews from March 2020 to April 2020 at a large tertiary academic urban hospital center. Interview guides were informed by the Resilience Framework for Public Health Emergency Preparedness and analyzed using a directed content analysis approach., Results: Fifty-five clinical staff participated in the study. Three themes emerged from the data (1) Risk assessment and planning: "The powder keg," (2) Innovative evolution of roles and responsibilities, and (3) Pandemic response and capacity. In the early phases of the pandemic, participants reported varying levels of risks for dying. However, most participants adapted to practice changes and became innovative in their roles over time. Hierarchies were less relevant during care delivery, whereas team collaboration became crucial in managing workforce capacity., Discussion: As the pandemic progressed, staff preparedness evolved through a trial-and-error approach., Conclusions: The pandemic is evolving as is clinical staff preparedness to meet the demands of a pandemic. In order to get a grasp on the crisis, clinical staff relied on each other and resorted to new workarounds., (Copyright © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Diagnosis and hospitalization for COVID-19 are disproportionately higher among black persons. The purpose of this study was to explore the lived experience of being diagnosed with COVID-19 among black patients. Semistructured one-on-one interviews with black patients diagnosed with COVID-19 were conducted. Data were analyzed using conventional content analysis and a directed content approach. Fifteen patients participated and 3 themes were identified: Panic amidst a COVID-19 diagnosis, Feeling the repercussion of the diagnosis, and Personal assessment of risks within one's individual environment. Fear of dying, inadequate health benefits, financial issues, and worries about spreading the virus to loved ones were acknowledged by the patients as critical areas of concerns. Majority of the patients looked to God as the ultimate way of surviving COVID-19. However, none of the patients reported receiving support for spiritual needs from health care providers. This is the first study to investigate the lived experience of being diagnosed with COVID-19 among black patients. Our results highlight several factors that put this group at increased risk for COVID-19 and where additional strategies are needed to address these inadequacies. Integrating public health interventions to reduce socioeconomic barriers and integrating spirituality into clinical care could improve patient care delivery., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Objective: The purpose of this study was to understand the physical and psychological impact of high stress clinical environments and contributory factors of burnout in multidisciplinary healthcare workforce during the initial outbreak of COVID-19., Method: In-person qualitative interviews informed by an adaptation of Karasek's Job Demand-control model were conducted with a convenience sample of healthcare workforce from March to April 2020., Results: Themes emerging from interviews coalesced around three main areas: fear of uncertainty, physical and psychological manifestations of stress, and resilience building. Shifting information, a lack of PPE, and fear of infecting others prompted worry for those working with Covid-infected patients. Participants reported that stress manifested more psychologically than physically. Individualized stress mitigation efforts, social media and organizational transparency were reported by healthcare workers to be effective against rising stressors., Conclusion: COVID-19 has presented healthcare workforce with unprecedented challenges in their work environment. With attention to understanding stressors and supporting clinicians during healthcare emergencies, more research is necessary in order to effectively promote healthcare workforce well-being., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to evaluate the psychometric properties of a newly developed survey tool measuring omissions in primary care., Methods: The Errors of Care Omission Survey (ECOS) is the only known tool to measure critical omissions ("errors") in primary care from the perspectives of primary care providers (PCPs), both physicians and nurse practitioners. The tool has 31 items grouped into the following four subscales: Self-Management Support, Follow-up, Emotional Health Support, and Care Integration. A cross-sectional survey design was used to mail the tool to PCPs and 582 PCPs in one state in the U.S. completed and returned the survey. Exploratory factor analysis with target rotation was carried out. Internal consistency reliability of identified subscales was investigated., Results: Four factors emerged representing domains of omissions in primary care. The original Follow-up and Care Integration subscales were retained. The items on Self-Management Support and Emotional Health Support subscales loaded differently on two factors, which were labeled Patient Self-Management and Family Engagement subscales, suggesting that conceptually PCPs separate patient and family involvement in patient care. Seven poorly performing or redundant items were removed. The remaining 24 items measure patient self-management, family engagement, follow-up, and care integration domains of omissions in primary care. The ECOS subscales have acceptable internal consistency reliability with Cronbach's α ranging from 0.90 to 0.97., Conclusions: The ECOS can be used in primary care to identify critical omissions, so actions can be taken by clinicians and administrators to prevent them before they result in patient harm. Further testing of the ECOS is recommended with diverse samples., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: To assess the intervention effects of BREATHE (BRief intervention to Evaluate Asthma THErapy), a novel brief shared decision-making intervention and evaluate feasibility and acceptability of intervention procedures., Design: Group-randomized longitudinal pilot study., Methods: In total, 80 adults with uncontrolled persistent asthma participated in a trial comparing BREATHE (N = 40) to a dose-matched attention control intervention (N = 40). BREATHE is a one-time shared decision-making intervention delivered by clinicians during routine office visits. Ten clinicians were randomized and trained on BREATHE or the control condition. Participants were followed monthly for 3 months post-intervention. Data were collected from December 2017 - May 2019 and included surveys, lung function tests, and interviews., Results: Participants were Black/multiracial (100%) mostly female (83%) adults (mean age 45). BREATHE clinicians delivered BREATHE to all 40 participants with fidelity based on expert review of audiorecordings. While the control group reported improvements in asthma control at 1-month and 3-month follow-up, only BREATHE participants had better asthma control at each timepoint (β = 0.77; standard error (SE)[0.17]; p ≤ 0.0001; β = 0.71; SE[0.16]; p ≤ 0.0001; β = 0.54; SE[0.15]; p = .0004), exceeding the minimally important difference. BREATHE participants also perceived greater shared decision-making occurred during the intervention visit (β = 7.39; SE[3.51]; p = .03) and fewer symptoms at follow-up (e.g., fewer nights woken, less shortness of breath and less severity of symptoms) than the controls. Both groups reported improved adherence and fewer erroneous medication beliefs., Conclusion: BREATHE is a promising brief tailored intervention that can be integrated into office visits using clinicians as interventionists. Thus, BREATHE offers a pragmatic approach to improving asthma outcomes and shared decision-making in a health disparity population., Impact: The study addressed the important problem of uncontrolled asthma in a high-risk vulnerable population. Compared with the dose-matched attention control condition, participants receiving the novel brief tailored shared decision-making intervention had significant improvements in asthma outcomes and greater perceived engagement in shared decision-making. Brief interventions integrated into office visits and delivered by clinicians may offer a pragmatic approach to narrowing health disparity gaps. Future studies where other team members (e.g., office nurses, social workers) are trained in shared decision-making may address important implementation science challenges as it relates to adoption, maintenance, and dissemination. TRAIL REGISTRATION: clinicaltrials.gov # NCT03300752., (© 2020 John Wiley & Sons Ltd.)

Poor practice environments contribute to burnout, but favorable environments containing support, resources, autonomy, and optimal relations with colleagues may prevent burnout. Compared to all nurse practitioners (NPs), 69% of these NPs provide primary care to patients, yet it is unknown whether the practice environment is associated with NP burnout. A study to examine environmental factors related to NP burnout was conducted. Overall, 396 NPs completed the survey and 25.3% were burnt-out. Higher scores on the professional visibility, NP-physician relations, NP-administration relations, independent practice and support subscales were associated with 51%, 51%, 58%, and 56% lower risk of NP burnout, respectively., Competing Interests: Conflicts of Interest: The authors declare no conflicts of interest.

Background: Prevalence of electronic health records (EHRs) has significantly increased, and EHRs are a known contributor to clinician burnout. However, it is unknown whether the use of multifunctional EHRs is associated with nurse practitioner (NP) burnout in primary care practices. This is a major gap in the literature because 69% of practicing NPs deliver primary care services to patients., Purpose: This study aimed to investigate whether the use of multifunctional EHRs is associated with primary care NP burnout., Method: This study is a secondary analysis of cross-sectional survey data collected from NPs in two states (Pennsylvania and New Jersey). Nurse practitioners completed surveys measuring burnout, use of multifunctional EHRs, demographics, and characteristics of their practice. Use of multifunctional EHRs was operationalized using two items-computerized capabilities and electronic reminder systems. Burnout was measured using a validated, single item asking NPs to self-report their feelings of burnout. A multilevel cox regression model was built to test for associations between the use of multifunctional EHRs and NP burnout., Results: Of 396 NPs included, 25.3% reported burnout. The use of multifunctional EHRs did not increase primary care NP burnout (risk ratio = 0.30, 95% confidence interval = 0.13-0.71, p = .01)., Implications for Practice: With 25.3% of NPs burned out, it is imperative to reduce NP burnout. However, computerized capabilities and electronic reminder systems did not contribute to feelings of NP burnout. Future research examining other EHR components is needed to understand which features of the EHR contribute to NP burnout., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

Background: New York State (NYS) has approximately 4.7 million Medicaid beneficiaries with 75% having at least one or more chronic conditions. An estimated 10% of Medicaid beneficiaries seek emergency department (ED) services for nonurgent matters. It is unclear if an increased supply of nurse practitioners (NPs) and physician assistants (PAs) impact utilization of ED and subsequent hospitalizations for chronic conditions., Purpose: To investigate the relationship between NYS workforce supply (physicians, NPs, and PAs) and 1) ED use and 2) in-patient hospitalizations for chronically ill Medicaid beneficiaries., Methods: A cross-sectional study design was employed by calculating total workforce supply per NYS county and the proportion of physicians, NPs, and PAs per total number of Medicaid beneficiaries. We extracted the frequencies of all NYS Medicaid beneficiary chronic condition-related ED visits and in-patient admissions. Medicaid beneficiaries were considered to have a chronic condition if there was a claim indicating that the beneficiary received a service or treatment for this specific condition. We calculated the proportion of ED visits/beneficiary for each chronic disease category and the proportion of category-specific in-patient hospitalizations per the number of beneficiaries with that diagnosis., Results: As the NP/beneficiary proportion increased, ED visits for dual and nondual eligible beneficiaries decreased (p = .007; β = -2.218; 95% confidence interval [CI]: -3.79 to -0.644 and p = .04; β = -2.698; 95% CI: -5.268 to -0.127, respectively)., Implications for Practice: Counties with a higher proportion of NPs and PAs had significantly lower numbers of ED visits and hospitalizations for Medicaid beneficiaries., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2020 American Association of Nurse Practitioners.)

Background: Research examining RNs' experiences during the COVID-19 pandemic is lacking, thus inhibiting efforts to optimize nursing care delivery and patient outcomes during the current pandemic and future public health emergencies., Objective: To explore the experience of being a registered nurse caring for patients with COVID-19 at an urban academic medical center during the early stages of the pandemic., Design: Qualitative descriptive study, guided by Donabedian's Quality Framework for Evaluation of Healthcare Delivery which focuses on structures, processes, and outcomes of care delivery., Setting: Urban academic medical center in the northeast United States., Participants: Registered nurses cared for or caring for patients with COVID-19, age ≥18 years old, and English-speaking., Methods: Participants were recruited for individual in-person semi-structured interviews. Interviews occurred during March and April 2020 and were recorded and transcribed. Transcripts were analyzed by two researchers using emergent qualitative content analysis to identify themes., Results: Twenty-one registered nurses participated in the study. Three themes emerged from the data, included one relevant to structures and two relevant to processes of care during the pandemic. Registered nurses perceived the clinical context as highly dynamic, but quickly adapted to pandemic-related care delivery. They felt a "sense of duty" to care for patients with COVID-19, despite being fearful of acquiring or spreading infection. Compared to clinical colleagues, registered nurses reported increased patient exposure and performed tasks previously assigned to other clinical team members., Conclusion: Roles and nursing practice processes evolved to meet the demand for care despite challenges. Registered nurses require adequate protection for their frontline role which may consist of increased patient exposure compared to clinical colleagues, emotional support, and clear clinical guidance. A deeper understanding of how a public health emergency, such as the COVID-19 pandemic, affects nursing practice can guide future efforts to optimize healthcare structures, nursing care processes, and patient outcomes. Our study can inform strategies for providing registered nurses with adequate communication, protection, and resources during the COVID-19 pandemic and future similar public health emergencies., Competing Interests: None, (© 2020 The Authors.)

Background: Nursing Assistants (NA) who feel empowered tend to perform their duties better, have higher morale and job satisfaction, and are less likely to leave their jobs. Organizational empowerment practices in hospitals likely shape the psychological experiences of empowerment among these personnel; however, little is known about this relationship., Objective: We used qualitative inquiry to explore the relationship between organizational empowerment structural components and feelings of psychological empowerment among hospital frontline workers during a public health emergency., Methods: Kanter's Theory of Structural Empowerment and Spreitzer's Psychological Empowerment in the Workplace Framework were applied to identify the conceptual influences of organizational practices on psychological experiences of empowerment. In-depth interviews were conducted with a convenience sample of NAs, caring for hospitalized COVID-19 patients. Directed content analysis was performed to generate a data matrix consisting of the psychological experiences of meaning, competence, self-determination, and impact embedded under the organizational structural components of information, resources, support, and opportunity., Results: Thirteen NAs (mean age = 42 years, 92% female) completed interviews. Information , or lack thereof, provided to the NAs influenced feelings of fear, preparation, and autonomy. Resources (e.g., protocols, equipment, and person-power) made it easier to cope with overwhelming emotions, affected the NAs' abilities to do their jobs, and when limited, drove NAs to take on new roles. NAs noted that support was mostly provided by nurses and made the NAs feel appreciated, desiring to contribute more. While NAs felt they could consult leadership when needed, several felt leadership showed little appreciation for their roles and contributions. Similar to support, the opportunity to take care of COVID-19 patients yielded a diverse array of emotions, exposed advances and gaps in NA preparation, and challenged NAs to autonomously develop new care practices and processes., Conclusion: Management and empowerment of healthcare workers are critical to hospital performance and success. We found many ways in which the NAs' psychological experiences of empowerment were shaped by the healthcare system's empowerment-related structural conditions during a public health emergency. To further develop an empowered and committed critical workforce, hospitals must acknowledge the organizational practice influence on the psychological experiences of empowerment among NAs., Competing Interests: Competing interests‘The Authors declare that they have no competing interests.’, (© The Author(s) 2020.)

Background: The organizational environment can foster or impede full deployment of advance practice registered nurses (APRNs), affecting the quality of care and patient outcomes. Given the critical role APRNs play in health care, it is important to understand organizational factors that promote or hinder APRN practice to maximize the potential of this workforce in health care systems., Purpose: The aim of this study was to synthesize evidence about APRN practice environments, identify organizational facilitators and barriers, and make recommendations for better APRN utilization., Methods: A literature search was conducted in CINAHL, PubMed, and PsychInfo, yielding 366 studies. No time or geographic limitations were applied. Study quality was appraised using the National Institutes of Health National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Studies., Results: Thirty studies conducted in the United States, Canada, and the Netherlands met inclusion criteria. The majority of the studies involved nurse practitioners. Facilitators to optimal practice environment were autonomy/independent practice and positive physician/APRN relations. Barriers included policy restrictions on practice, poor physician relations, poor administrator relations, and others' lack of understanding of the APRN role. Barriers correlate with job dissatisfaction and increased intent to leave job., Practice Implications: The review highlights the importance of physician and administration relations, organizational-level policies, and colleagues' understanding of the APRN role in promoting effective practice environments. Organizations should align policy reform efforts with factors that foster positive APRN practice environments to efficiently and effectively utilize this increasingly vital workforce. Future research is warranted.

Background: Inhaled corticosteroids (ICS) are the foundation of asthma management. However, ICS non-adherence is common. Black adults have lower ICS adherence than white adults, which likely contributes, in part, to the asthma disparities that Black adults experience., Objective: To explore how Black adults with uncontrolled asthma and their primary care providers communicated about ICS non-adherence and used shared decision-making to identify strategies to increase ICS use., Design: Eighty routine clinical visits for uncontrolled asthma were audio recorded and inductively analyzed using methods adapted from grounded theory methodology., Participants: Study participants included 80 Black adults (83% female) largely low-income (83% Medicaid) and their 10 primary care providers. The study settings were 2 Federally Qualified Health Centers., Key Results: Three overarching themes were identified: (1) ICS misuse and lack of knowledge; (2) external influences informed personal misconceptions about ICS; and (3) patient-provider communication to individualize plan of care., Conclusions: Reasons for ICS non-adherence in Black adults with uncontrolled asthma offer potential targets for interventions that facilitate enhanced adherence. Future research should include PCP training on strategies that support patient-centered care, such as communication, shared decision-making and patient engagement.

Globally, advanced practice nurses (APNs) provide high-quality chronic disease care to patients, yet the cost-effectiveness of their services is minimally explored. This review aims to determine the cost-effectiveness of chronic disease care provided by APNs compared to physicians globally.

Purpose: To explore perspectives of primary care providers (PCPs), including physicians and nurse practitioners (NPs), about delivery of mental health care in primary care settings., Methods: We used a qualitative descriptive designed convenience sample of physicians (N = 12) and NPs (N = 14) through face-to-face interviews in New York State., Results: Three themes emerged: 1) prioritization of patient needs; 2) applicability of mental health care in primary care settings; and 3) physician and NP approaches to mental health care., Conclusions: PCPs recognized importance of addressing patients' mental health care needs and barriers in primary care practices., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To evaluate the preliminary effectiveness of the BRief Evaluation of Asthma THerapy intervention, a 7-min primary care provider-delivered shared decision-making protocol that uses motivational interviewing to address erroneous asthma disease and medication beliefs., Design: A multi-centre masked two-arm group-randomized clinical trial., Methods: This 2-year pilot study is funded (September 2016) by the National Institute of Nursing Research. Eight providers will be randomized to one of two arms: the active intervention (N = 4) or a dose-matched attention control (N = 4). Providers will deliver the intervention to which they were randomized to 10 Black adult patients with uncontrolled asthma (N = 80). Patients will be followed three months postintervention to test the preliminary intervention effects on asthma control (primary outcome) and on medication adherence, lung function, and asthma-related quality of life (secondary outcomes)., Discussion: This study will evaluate the preliminary impact of a novel shared decision-making intervention delivered in a real world setting to address erroneous disease and medication beliefs as a means of improving asthma control in Black adults. Results will inform a future, large-scale randomized trial with sufficient power to test the intervention's effectiveness., Impact: Shared decision-making is an evidence-based intervention with proven effectiveness when implemented in the context of labour- and time-intensive research protocols. Medication adherence is linked with the marked disparities evident in poor and minority adults with asthma. Addressing this requires a novel multifactorial approach as we have proposed. To ensure sustainability, shared decision-making interventions must be adapted to and integrated into real-world settings., Trial Registration: Registered at clincialtrials.gov as NCT03036267 and NCT03300752., (© 2018 John Wiley & Sons Ltd.)