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Background: This article evaluates a single-institution educational innovation using course-specific open educational resources (OER). Method: This educational innovation uses a course-specific library resource guide of OERs and evaluates students' perspectives on the quality, integration, and experience with the resources. At the completion of a nursing graduate course, the OER Satisfaction Scale was administered to the course participants. The course-specific OERs were assessed compared to students' experiences with traditional course materials. Results: The overall score on the OER Satisfaction Scale was 4.01 on a 5-point Likert Scale. Students appreciated that the resources were free and found that the information was manageable and easy to navigate. However, they were challenged with shutting out other distractions and taking useful notes. Conclusion: Using OERs enhanced student engagement with the course content by requiring learners to assume a more active role as course participants. Further work is needed to understand the effectiveness of OERs, particularly in graduate nursing education. [ J Nurs Educ . 2020;59(10):577–580.]

Key Points Question What is the association of a billed advance care planning (ACP) visit with intensive use of health care services at the end of life (EOL) for Medicare beneficiaries with serious illness? Findings In this cohort study of claims data of 955 777 Medicare beneficiaries with serious illness who died in 2017 and 2018, billed ACP visits that occurred during the decedents’ EOL course but before the last month of life were relatively uncommon. However, their occurrence was associated with less intensive use of EOL health care services. Meaning The findings of this cohort study suggest that ACP is associated with less intensive use of EOL health care services., Importance Advance care planning (ACP) is intended to maximize the concordance of preferences with end-of-life (EOL) care and is assumed to lead to less intensive use of health care services. The Centers for Medicare & Medicaid Services began reimbursing clinicians for ACP discussions with patients in 2016. Objective To determine whether billed ACP visits are associated with intensive use of health care services at EOL. Design, Setting, and Participants This prospective patient-level cohort analysis of seriously ill patients included Medicare fee-for-service beneficiaries who met criteria for serious illness from January 1 to December 31, 2016, and died from January 1, 2017, to December 31, 2018. Analyses were completed from November 1, 2020, to March 31, 2021. Main Outcomes and Measures Five measures of EOL health care services used (inpatient admission, emergency department visit, and/or intensive care unit stay within 30 days of death; in-hospital death; and timing of first hospice bill) and a measure of EOL expenditures. Analyses were adjusted for age, race and ethnicity, sex, Charlson Comorbidity Index, Medicare-Medicaid dual eligibility, and expenditure by hospital referral region (high, medium, or low). The primary exposure was receipt of a billed ACP service classified as none, timely (>1 month before death), or late (first ACP visit ≤1 month before death). Results Of the 955 777 Medicare beneficiaries who met criteria for serious illness in 2016 and died in 2017 or 2018, 522 737 (54.7%) were women, 764 666 (80.0%) were 75 years or older, and 822 684 (86.1%) were non-Hispanic White individuals. Among the study population, 81 131 (8.5%) had a timely ACP visit, and an additional 22 804 (2.4%) had a late ACP visit. After multivariable adjustment, compared with patients without any billed ACP visit, patients with a timely ACP visit experienced significantly less intensive EOL care on 4 of 5 measures, including in-hospital death (adjusted odds ratio [aOR], 0.85; 95% CI, 0.84-0.87), hospital admission (aOR, 0.84; 95% CI, 0.83-0.85), intensive care unit admission (aOR, 0.87; 95% CI, 0.85-0.88), and emergency department visit (OR, 0.83; 95% CI, 0.82-0.84). Only small or insignificant differences in late hospice use or mean total EOL expenditures were noted. Compared with patients without ACP, patients with late ACP experienced more intensive EOL care, including in-hospital death (aOR, 1.22; 95% CI, 1.19-1.26), hospital admission (aOR, 5.28; 95% CI, 5.07-5.50), intensive care unit admission (aOR, 1.57; 95% CI, 1.53-1.62), and emergency department visit (aOR, 3.87; 95% CI, 3.72-4.02). Conclusions and Relevance In this cohort study of US Medicare beneficiaries, billed ACP services during the EOL course of patients with serious illness were relatively uncommon, but if they occurred before the last month of life, they were associated with less intensive use of EOL services. Further research on the variables affecting hospice use and expenditures in the EOL period and the differential effect of late ACP is recommended to understand the relative role of ACP in achieving goal-concordant care., This cohort study tests the hypothesis that having a billed advance care planning visit is associated with less intensive use of end-of-life health care services among Medicare beneficiaries with serious illness.

BACKGROUND Transgender and gender-expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. There is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among TGE adults. OBJECTIVE This study aims to qualitatively examine the risk and protective factors of cigarette smoking among TGE adults through real-world exemplars. METHODS We conducted a digital photovoice study among a purposeful sample of 47 TGE adults aged ≥18 years and currently smoking in the United States (March 2019-April 2020). Participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private Facebook or Instagram groups. Next, we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group. We analyzed participants’ photos, captions, and focus group transcripts and generated themes associated with smoking risk and protective factors. RESULTS We identified 6 major themes of risk and protective factors of smoking among TGE individuals: experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues. We describe and illustrate each theme using exemplar photos and quotes. CONCLUSIONS The findings of this study will inform future community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGE individuals.

Author(s): Reckrey, Jennifer M; Gazarian, Priscilla; Reuben, David B; Latham, Nancy K; McMahon, Siobhan K; Siu, Albert L; Ko, Fred C | Abstract: Background/objectivesEvaluations of complex models of care for older adults may benefit from simultaneous assessment of intervention implementation. The STRIDE (Strategies To Reduce Injuries and Develop confidence in Elders) pragmatic trial evaluated the effectiveness of a multifactorial intervention to reduce serious fall injuries in older adults. We conducted multi-level stakeholder interviews to identify barriers to STRIDE intervention implementation and understand efforts taken to mitigate these barriers.DesignQualitative interviews with key informants.SettingTen clinical trial sites affiliated with practices that provided primary care for persons at increased risk for fall injuries.ParticipantsSpecially trained registered nurses working as Falls Care Managers (FCMs) who delivered the intervention (nn=n13 individual interviews), Research Staff who supervised trial implementation locally (nn=n10 group interviews, 23 included individuals), and members of Central Project Management and the National Patient Stakeholder Council who oversaw national implementation (nn=n2 group interviews, six included individuals).MeasurementsA semi-structured interview guide derived from the consolidated framework for implementation research (CFIR).ResultsWe identified eight key barriers to STRIDE intervention implementation. FCMs navigated complex relationships with patients and families while working with Research Staff to implement the intervention in primary care practices with limited clinical space, variable provider buy-in, and significant primary care practice staff and provider turnover. The costs of the intervention to individual patients and medical practices amplified these barriers. Efforts to mitigate these barriers varied depending on the needs and opportunities of each primary care setting.ConclusionThe many barriers to implementation and the variability in how stakeholders addressed these locally may have affected the overall STRIDE intervention's effectiveness. Future pragmatic trials should incorporate simultaneous implementation aims to better understand how research interventions translate into clinical care that improves the lives of older adults.

Author(s): Gill, Thomas M; Bhasin, Shalender; Reuben, David B; Latham, Nancy K; Araujo, Katy; Ganz, David A; Boult, Chad; Wu, Albert W; Magaziner, Jay; Alexander, Neil; Wallace, Robert B; Miller, Michael E; Travison, Thomas G; Greenspan, Susan L; Gurwitz, Jerry H; Rich, Jeremy; Volpi, Elena; Waring, Stephen C; Manini, Todd M; Min, Lillian C; Teresi, Jeanne; Dykes, Patricia C; McMahon, Siobhan; McGloin, Joanne M; Skokos, Eleni A; Charpentier, Peter; Basaria, Shehzad; Duncan, Pamela W; Storer, Thomas W; Gazarian, Priscilla; Allore, Heather G; Dziura, James; Esserman, Denise; Carnie, Martha B; Hanson, Catherine; Ko, Fred; Resnick, Neil M; Wiggins, Jocelyn; Lu, Charles; Meng, Can; Goehring, Lori; Fagan, Maureen; Correa-de-Araujo, Rosaly; Casteel, Carri; Peduzzi, Peter; Greene, Erich J | Abstract: Background/objectivesIn the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.DesignPragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.SettingA total of 86 primary care practices within 10 U.S. healthcare systems.ParticipantsA random subsample of 743 persons aged 75 and older.MeasurementsThe well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.ResultsParticipants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.ConclusionsSTRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

Background Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. Method In this national study, we conducted semi-structured interviews with purposively selected clinicians from 6 diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians’ perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. Results Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians’ difficulty approaching ACP (preconceived views of patients’ preferences, narrow definitions of successful ACP, and lack of institutional resources), while the final theme illustrated facilitators to ACP (acknowledging bias and rejecting stereotypes, mission-driven focus on ACP, and acceptance of all preferences). Conclusions Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.

RESEARCH OBJECTIVE: Recognizing that advance care planning (ACP) supports alignment of end‐of‐life care with an individual’s preferences and is associated with improved patient outcomes, and Medicare initiated billing codes for ACP in 2016. Adoption of the ACP codes during the first year has been low. In order to inform Medicare on opportunities to promote the use of the program, we now examine Year 2 trends in uptake by patient and provider characteristics. STUDY DESIGN: ACP claims in 2016‐7 were identified by CPT codes. We examined (a) the total annual number of claims; (b) beneficiary ACP use (number and rate of Medicare beneficiaries having one or more ACP visits, annually and cumulative over 2 years); (c) provider ACP claim rate (ACP claims per 10,000 total claims); and (d) spread (increase in total number of unique billing providers by NPI). POPULATION STUDIED: 348 190 ACP claims from a 20% random sample of fee‐for‐service (FFS) Medicare beneficiaries continuously enrolled from 2016 to 2017. PRINCIPAL FINDINGS: The number of ACP claims increased from 137 079 in 2016 to 348,190 in 2017, an increase of 154%. ACP USE RATES: The cumulative beneficiary ACP use rate increased from 2.12% in 2016 to 3.28% in 2017. Persons over the age of 85 had the highest ACP cumulative use rate (6.15%) in 2017 and the highest percent annual increase in number of users (160%). Whites had the highest ACP cumulative use rate (3.92%); however, blacks had the highest percent annual increase in number of users (176%). Females had the highest ACP cumulative use rate (4.20%); however, males had a slightly higher percent annual increase in users (155%). Provider ACP Claim Rates per 10,000: Among specialties, hospice and palliative care providers had the highest ACP cumulative claim rate (93.16) in 2017, although acute care specialists had the largest percent increase (243%). By provider role, Clinical Nurse Specialists had the highest ACP claim rate (10.16), although Physician Assistants had the largest percent increase (188%.) The majority of claims (87.2%) were in urban areas, although small metropolitan areas saw the largest percent increase 161%. In terms of spread, the total number of unique billing providers increased from 14,207 in 2016 to 26,434 in 2017, an increase of 86%. CONCLUSIONS: The use of ACP codes continues to increase; however, the increase in uptake and spread among providers is still quite low. Despite larger gains among Blacks and men, older female and white beneficiaries remain the group most frequently receiving an ACP visit claim. The use of the ACP billing codes has spread to new clinician specialties and provider roles and to small metropolitan areas. IMPLICATIONS FOR POLICY OR PRACTICE: There are many barriers to integrating ACP into practice, and the use of ACP billing codes is one method to incentivize the behavior. Despite the growing use of ACP codes, the slow uptake is notable. The use of ACP billing codes is underutilized, and increased promotion by CMS may be warranted, particularly targeting younger, male patients and more clinical specialties in rural areas. PRIMARY FUNDING SOURCE: National Institutes of Health.

BackgroundInjuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined.MethodsWe conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group.ResultsThe demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups.ConclusionsA multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

BACKGROUNDProviding information to patients in intensive care units and their families is challenging. Patients often are admitted unexpectedly and experience stress and uncertainty. One source of stress has been identified as unclear, uncoordinated, or inconsistent communication and information. Despite the need for information, no centrally located, easily accessible, standardized intensive care unit education content exists.OBJECTIVETo identify educational content for patients in the intensive care unit and their families across 4 different hospitals, develop a general content database, and organize the general content into a framework for education of patients and their families.METHODSEducational content for patients in the intensive care units of 4 participating hospitals was collected and a gap analysis was performed.RESULTSKey content format and categories were identified. Educational content was organized into an information pathway divided into 3 phases: intensive care unit arrival; understanding the intensive care unit and partnering in care; and intensive care unit transitions. The gap analysis revealed substantial variation in content format and categories.CONCLUSIONSStructuring a digital learning center using different stages of the patient’s stay in the intensive care unit and placing resources in the context of an information pathway can help coordinate education for these patients and their families, and creates a consistent communication guide for clinicians as well. The optimal digital format should be considered in designing the learning center.

In response to the epidemic of falls and serious falls-related injuries in older persons, in 2014, the Patient Centered Outcomes Research Institute (PCORI) and the National Institute on Aging funded a pragmatic trial, Strategies to Reduce Injuries and Develop confidence in Elders (STRIDE) to compare the effects of a multifactorial intervention with those of an enhanced usual care intervention. The STRIDE multifactorial intervention consists of five major components that registered nurses deliver in the role of falls care managers, co-managing fall risk in partnership with patients and their primary care providers (PCPs). The components include a standardized assessment of eight modifiable risk factors (medications; postural hypotension; feet and footwear; vision; vitamin D; osteoporosis; home safety; strength, gait, and balance impairment) and the use of protocols and algorithms to generate recommended management of risk factors; explanation of assessment results to the patient (and caregiver when appropriate) using basic motivational interviewing techniques to elicit patient priorities, preferences, and readiness to participate in treatments; co-creation of individualized falls care plans that patients' PCPs review, modify, and approve; implementation of the falls care plan; and ongoing monitoring of response, regularly scheduled re-assessments of fall risk, and revisions of the falls care plan. Custom-designed falls care management software facilitates risk factor assessment, the identification of recommended interventions, clinic note generation, and longitudinal care management. The trial testing the effectiveness of the STRIDE intervention is in progress, with results expected in late 2019.

Background: End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. Objective: We investigated occupation as a source of variation in EOL care intensity. Methods: Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. Results: Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US$9991 and 42% of population mean expenditure ( P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. Conclusion: Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.

RESEARCH OBJECTIVE: Vulnerable patients, such as racial and ethnic minorities, infrequently participate in advance care planning (ACP). Reasons underlying low uptake are not well understood. We sought to examine clinician perspectives regarding barriers to ACP among vulnerable populations. STUDY DESIGN: Case studies with semi‐structured interviews. POPULATION STUDIED: Health systems were purposively selected by an expert advisory panel to ensure diversity of health system size, region, type (ie, academic, public, nonprofit), and religious affiliation. Within each site, a purposive sample of 10–13 clinicians was selected by the chief medical officer or a palliative care leader based on clinician role (eg, physicians, nurse practitioners, social workers), specialty, and experience with ACP. PRINCIPAL FINDINGS: We interviewed 75 clinicians at 6 health systems after which we reached thematic saturation. When asked to describe characteristics of patients with whom they have difficulty discussing ACP, clinicians most frequently identified racial and ethnic minorities and non‐English or non‐native English speakers. Four themes emerged that characterized clinicians’ perspectives regarding barriers to ACP among vulnerable patients. First, clinicians had preconceived notions that vulnerable patients were reluctant to participate in ACP due to mistrust of the health care system or cultural beliefs that preclude discussions about death and dying. Second, these preconceptions led to clinicians feeling anxious while discussing ACP with vulnerable patients, resulting in their avoiding ACP altogether or undertaking only cursory explorations of these patients’ goals and values. Third, clinicians had fixed beliefs about successful ACP (eg, identifying a single decision maker, completing legal documents) that were often discordant with preferences among vulnerable patients. Fourth, clinicians reported insufficient institutional resources to properly engage vulnerable patients, including in‐person translators with training in discussing ACP. CONCLUSIONS: We identified several clinician‐ and institution‐level factors that may mediate low uptake of ACP among vulnerable patients, suggesting that observed differences in rates of ACP between vulnerable patients and others may be modifiable. IMPLICATIONS FOR POLICY OR PRACTICE: Current efforts to promote ACP, including Medicare’s ACP billing codes, may not be effective in all patient populations due to clinician‐ and institution‐level barriers to ACP that are unlikely to be addressed by financial incentives. Additional research is needed to more completely characterize clinician decision making regarding ACP among vulnerable patients, including developing interventions to modify heuristics that may lead to disparities with a goal of ensuring equitable access to ACP among all patients. Institutions should also consider investing in more robust translator programs to facilitate ACP discussions with non‐English and non‐native English speakers. PRIMARY FUNDING SOURCE: National Institutes of Health.

Background This paper describes a protocol for determining the incidence of serious fall injuries for Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE), a large, multicenter pragmatic clinical trial with limited resources for event adjudication. We describe how administrative data (from participating health systems and Medicare claims) can be used to confirm participant-reported events, with more time- and resource-intensive full-text medical record data used only on an “as-needed” basis. Methods STRIDE is a pragmatic cluster-randomized controlled trial involving 5451 participants age ≥ 70 and at increased risk for falls, served by 86 primary care practices in 10 US health systems. The STRIDE intervention involves a nurse falls care manager who assesses a participant’s underlying risks for falls, suggests interventions using motivational interviewing, and then creates, implements and longitudinally follows up on an individualized care plan with the participant (and caregiver when appropriate), in partnership with the participant’s primary care provider. STRIDE’s primary outcome is serious fall injuries, defined as a fall resulting in: (1) medical attention billable according to Medicare guidelines with a) fracture (excluding isolated thoracic vertebral and/or lumbar vertebral fracture), b) joint dislocation, or c) cut requiring closure; OR (2) overnight hospitalization with a) head injury, b) sprain or strain, c) bruising or swelling, or d) other injury determined to be “serious” (i.e., burn, rhabdomyolysis, or internal injury). Two sources of data are required to confirm a serious fall injury. The primary data source is the participant’s self-report of a fall leading to medical attention, identified during telephone interview every 4 months, with the confirmatory source being (1) administrative data capturing encounters at the participating health systems or Medicare claims and/or (2) the full text of medical records requested only as needed. Discussion Adjudication is ongoing, with over 1000 potentially qualifying events adjudicated to date. Administrative data can be successfully used for adjudication, as part of a hybrid approach that retrieves full-text medical records only when needed. With the continued refinement and availability of administrative data sources, future studies may be able to use administrative data completely in lieu of medical record review to maximize the quality of adjudication with finite resources. Trial registration ClinicalTrials.gov (NCT02475850). Electronic supplementary material The online version of this article (10.1186/s40621-019-0190-2) contains supplementary material, which is available to authorized users.

Background Advance care planning (ACP) conversations help individuals exercise autonomy and make informed decisions about their care. There are many ACP resources available to support the process of advance care planning, yet available resources not universally accepted and under-utilized in clinical practice. Objective This study aims to systematically evaluate commonly available general ACP patient educational resources using a comprehensive approach to assess elements ranging from resource inclusion to health literacy. Design Systematic evaluation of general ACP educational resources Methods ACP educational resources were systematically identified and evaluated for: Patient Education Materials Assessment Tool (PEMAT) score, Flesch–Kincaid reading ease and grade level, cost, languages available, and categories of content including Advance directive/Healthcare proxy, Physician Order for Life-Sustaining Treatment (POLST), Living will, values, preferences, and goals. Results Educational resources (n = 20) were identified. These resources were classified as information resources, workbooks, interactive websites, or and activities/conversation guides. The average PEMAT understandability score was 86 (range 58–100) and the average actionability was 90 (range 40–100). Two resources met Flesch–Kincaid reading ease and grade level. Eight were available in English only, nine in two languages, and three in more than two languages. Three explicitly discussed completion of POLST forms. The majority of the resources adequately addressed the content of advanced directives and health care proxy, values, goals, and preferences for future care. The level of time commitment required to use each resource also varied considerably. Conclusion We present a comprehensive evaluation of resources to support ACP. Using the Transtheoretical Model, we provide a guide for the use of these educational resources based on patient readiness. This review allows clinicians to identify aspects of each resource that may be helpful in preparing older adults for future healthcare decsions. Our analysis has identified the need to continue to refine these educational resources so that they can reach a broad population with varying needs. Advance care planning (ACP) conversations help individuals exercise autonomy and make informed decisions about their care. There are many ACP educational resources available to support the process of advance care planning, yet available resources are not universally accepted and under-utilized in clinical practice. We present a comprehensive evaluation of 20 educational resources to support ACP. Educational resources were identified and evaluated for: Patient Education Materials Assessment Tool (PEMAT) score, Flesch–Kincaid reading ease and grade level, cost, languages available, and categories of content. Using the Transtheoretical Model, we provide a guide for the use of these educational resources based on patient readiness. This review allows clinicians to identify aspects of each resource that may be helpful in preparing older adults for future healthcare decisions. Our analysis has identified the need to continue to refine these educational resources so that they can reach a broad population with varying needs.

Therapeutic hypothermia has become a widely accepted intervention that is improving neurological outcomes following return of spontaneous circulation after cardiac arrest. This intervention is highly complex but infrequently used, and prompt implementation of the many steps involved, especially achieving the target body temperature, can be difficult. A checklist was introduced to guide nurses in implementing the therapeutic hypothermia protocol during the different phases of the intervention (initiation, maintenance, rewarming, and normothermia) in an intensive care unit. An interprofessional committee began by developing the protocol, a template for an order set, and a shivering algorithm. At first, implementation of the protocol was inconsistent, and a lack of clarity and urgency in managing patients during the different phases of the protocol was apparent. The nursing checklist has provided all of the intensive care nurses with an easy-to-follow reference to facilitate compliance with the required steps in the protocol for therapeutic hypothermia. Observations of practice and feedback from nursing staff in all units confirm the utility of the checklist. Use of the checklist has helped reduce the time from admission to the unit to reaching the target temperature and the time from admission to continuous electroencephalographic monitoring in the cardiac intensive care unit. Evaluation of patients’ outcomes as related to compliance with the protocol interventions is ongoing.

The STRIDE multifactorial intervention consists of a co-management model using a registered nurse Falls Care Manager (FCM) and includes four major components: 1) standardized assessment of 8 modifiable risk factors (medications, postural hypotension, feet and footwear, vision, vitamin D, osteoporosis, home safety, and strength, gait, and balance impairment); 2) use of structured visit notes, protocols, and algorithms to develop an individualized Falls Care Plan that is presented to the patient’s primary care physician for review, modification, and approval; 3) explanation of identified risks to the patient (and caregiver) with a description of suggested interventions, using motivational interviewing to elicit patient preferences and readiness to participate in treatments; and 4) ongoing monitoring of response to treatment and reassessment of risk factors at scheduled intervals with revision of the Care Plan as needed. Custom-designed falls care management software facilitates recommendation and note generation, tracking of care, and implementation of recommendations.

Background Delivering patient-centered care (PCC) is essential to our healthcare system. Patient dignity and respect are foundational elements of PCC. Understanding patients' and their care partner's perspectives on the meaning of dignity and respect within a clinical care environment is critical to achieving our goal of PCC. Objective The aim of the study was to understand how patients and their care partners define, describe, and experience dignity and respect during hospitalization. Methods We conducted a qualitative study with 22 patients and care partners hospitalized in high-acuity patient care areas in 1 academic medical center. Data collected from semistructured interviews were analyzed using grounded theory open coding in Atlas Ti software. Results Our data provide a definition of dignity and respect during hospitalization from the patient and care partner perspective and a conceptual model of the factors needed to enhance patients' and care partners' experience of dignity and respect in the hospital setting. Dignity was felt to be intrinsic to personhood including the recognition of that person's value by others. Respect was characterized as the behavioral or social norms that acknowledge dignity. Determinants of dignity and respect were categorized at the organizational (macro) level and within the microsystem between clinicians, patients, and their care partners. Conclusions The definition of dignity and respect and the conceptual model presented here represent an important supplement to our understanding of dignity and respect during hospitalization. Healthcare organizations should focus on the key factors found in this study to create a culture that treats patients with dignity and respect.

Aims and objectives To describe the cues and factors that nurses use in their decision-making when responding to clinical alarms. Background Alarms are designed to be very sensitive, and as a result, they are not very specific. Lack of adherence to the practice standards for electrocardiographic monitoring in hospital settings has been observed, resulting in overuse of the electrocardiographic monitoring. Monitoring without consideration of clinical indicators uses scarce healthcare resources and may even produce untoward circumstances because of alarm fatigue. With so many false alarms, alarm fatigue represents a symptom of a larger problem. It cannot be fixed until all of the factors that contribute to its existence have been examined. Design This was a qualitative descriptive study. Method This study was conducted at an academic medical centre located in the Northeast United States. Eight participants were enrolled using purposive sampling. Nurses were observed for two three-hour periods. Following each observation, the nurse was interviewed using the critical decision method to describe the cognitive processes related to the alarm activities. Qualitative data from the conducted interviews were analysed via an a priori framework founded in the critical decision method. Results This study reveals information, experience, guidance and decision-making as the four prominent categories contributing to nurses' decision-making in relation to alarm management. Managing technology was a category not identified a priori that emerged in the data analysis. Conclusion Nurses revealed a breadth of information needed to adequately identify and interpret monitor alarms, and how they used that information to put the alarms into the particular context of an individual patient's situations. Relevance to clinical practice Understanding the cues and factors nurses use when responding to cardiac alarms will guide the development of learning experiences and inform policies to guide practice.

Background An important role of the registered nurse is to identify patient deterioration by monitoring the patient condition and vital signs. Increasingly, this is supplemented with continuous electrocardiographic (ECG) monitoring. Continuous monitoring is inefficient in identifying deterioration because of the high number of false and nuisance alarms. Lack of strong evidence or formal guidelines for the care of patients receiving ECG monitoring has led clinicians to rely too heavily on this technology without consideration of its limitations. The nursing workload associated with alarm management remains unexamined. Objective To describe nurses' routine practices related to continuous ECG monitoring, frequency and types of alarms, their associated nursing interventions, and the impact on the patient's plan of care. Methods Design . Prospective, descriptive, observational study. Setting and participants . Between January 2011 and March 2011 we observed nine Registered Nurses providing care for patients receiving continuous ECG monitoring in non-critical care areas. The PI and two research assistants observed each nurse for two 3-h observation periods and recorded data on a researcher designed observation tool. At the end of each observation period, the observers printed the alarm events as recorded by the central monitoring computer. Results Nurses responded to 46.8% of all alarms. During the observation period, there were no dysrhythmia adverse events. One patient had a change in condition requiring transfer to a higher level of care. A range of nursing interventions occurred in response to alarms. Conclusion Nurses routine practices related to monitoring continue to reveal gaps in practice related to alarm management. Observations of practice also revealed the difficulties and complexities of managing alarm systems and the range of nursing interventions associated with managing alarms.

The focus of this article is the background and use of the critical decision method in nursing research. The purpose is to present a synthesis of the body of work whose authors used the critical decision method to explore nurses' cognitive work. For this integrative review of literature, I used the 5-step process: problem formulation, literature search, data evaluation, data analysis, and presentation. Synthesis of the 7 studies uncovered evidence of nurses' cognitive processes and demands of their practice environments and affirmed the method as a valuable tool for eliciting experienced nurses' practice knowledge making nursing expertise explicit.

Problem The confidence to act on clinical judgment, ask for help, and juggle multiple competing priorities is best developed within a clinical setting. Traditional classroom learning, which is often static, does not support learning these skills or help new students learn how to "be" a nurse. Student nurses need frequent and repeated exposure to expert nurses and clinical environments. Traditional teaching methods may not be sufficient to meet these needs. Method This project employs a strategy that supplies situated, context-driven learning with the aim of improving clinical reasoning by bringing real-world, real-time clinical scenarios into the classroom via audio conferencing. This classroom teaching strategy is based on the principles of learner-centered teaching, and the aim is to incorporate real-world clinical information into the classroom. Students are introduced to "real-time report" from special care areas as the basis for class activities and discussion. Findings Feedback on this model was sought through course evaluation data, focus groups with students, and participating nurses. NCLEX pass rate remained unchanged as a result of this teaching strategy. Conclusion In this model, the classroom changes from being a physical place where knowledge is acquired to a place where knowledge is translated from and applied to practice.

Objective: The goal of this project is to identify and evaluate Advanced Care Planning (ACP) decision aids so that they can be appropriately used by patients and health care providers to support the (ACP) process. Methods: A systematic evaluation of ACP decision aids was completed. ACP decision aids were evaluated for cost, languages available, Flesch-Kincaid reading ease and grade level, PEMAT Score, and categories of content including Advance directive/Health care proxy, POLST, Living will, values, preferences and goals. Results: Twenty decision aids were identified. The decision aids included workbooks, interactive websites, and activities/conversation guides. Conclusion: Our analysis has identified the need to continue to refine these decision aids so that they can reach a broad population with varying literacy and language needs. Practice Implications: The analysis presented can provide health care providers the confidence to use these decision aids in practice.

There is a significant body of research demonstrating that many hospitalized patients exhibit signs of clinical deterioration prior to experiencing a cardiopulmonary arrest (CPA).This qualitative study used the critical decision method to describe the cues and factors employed by nurses to identify and interrupt a potentially preventable CPA. The cues that nurses used in identifying a patient at risk for CPA were altered level of consciousness and other selected triggers from the Early Warning Scoring System (EWSS) combined with knowledge of the patient and the contextual features of the decision situation. Nurse characteristics that assisted in interrupting an adverse event included previous experiences in prearrest situations, and the ability to function as part of a team. Organizational characteristics that supported the nurse to interrupt included the availability of nurse-initiated monitoring equipment, experience and flexibility of staff, working with a collaborative team, and access to knowledge resources.

Background: The literature and research on nursing ethics and advocacy has shown that generally very few nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern and that often advocacy in nursing is not learned until after students have graduated and begun working. Objective: To evaluate the effectiveness of narrative pedagogy on the development of advocacy in student nurses, as measured by the Protective Nursing Advocacy Scale. Design: We tested the hypothesis that use of a narrative pedagogy assignment related to ethics would improve student nurse’s perception of their advocacy role as measured by the Protective Nursing Advocacy Scale using a quasi-experimental nonrandomized study using a pre-test, intervention, post-test design. Data collection occurred during class time from October 2012 to December 2012. The Protective Nursing Advocacy Scale tool was administered to students in class to assess their baseline and was administered again at the completion of the educational intervention to assess whether narrative pedagogy was effective in developing the nursing student’s perception of their role as a patient advocate. Ethical considerations: Students were informed that their participation was voluntary and that the data collected would be anonymous and confidential. The survey was not a graded assignment, and students did not receive any incentive to participate. The institutional review board of the college determined the study to be exempt from review. Setting: School of Nursing at a small liberal arts college in the Northeastern United States. Participants: A consecutive, nonprobability sample of 44 senior-level nursing students enrolled in their final nursing semester was utilized. Findings: Results indicated significant differences in student nurse’s perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story. Conclusion: Using the Protective Nursing Advocacy Scale, we were able to measure the effectiveness of narrative pedagogy on nursing student’s perception of the nurse’s advocacy role.

To assess the impact of an interventional patient-centered care model which wasdesigned to address patient expectations and improve patient and family experience during hospitalization. Based on our previous studies [1–3], we developed a structured, pro-active, patient-centered care model (Patient-SatisfActive model) comprised of interpersonal communicative steps between clinicians and patients that aims to improve patient experience during hospitalization. The model incorporates clinicians’ efforts …

The confidence to act on clinical judgment, ask for help, and juggle multiple competing priorities is best developed within a clinical setting. Traditional classroom learning, which is often static, does not support learning these skills or help new students learn how to "be" a nurse. Student nurses need frequent and repeated exposure to expert nurses and clinical environments. Traditional teaching methods may not be sufficient to meet these needs.This project employs a strategy that supplies situated, context-driven learning with the aim of improving clinical reasoning by bringing real-world, real-time clinical scenarios into the classroom via audio conferencing. This classroom teaching strategy is based on the principles of learner-centered teaching, and the aim is to incorporate real-world clinical information into the classroom. Students are introduced to "real-time report" from special care areas as the basis for class activities and discussion.Feedback on this model was sought through course evaluation data, focus groups with students, and participating nurses. NCLEX pass rate remained unchanged as a result of this teaching strategy.In this model, the classroom changes from being a physical place where knowledge is acquired to a place where knowledge is translated from and applied to practice.

An ever-increasingly complex health care environment requires practitioners who can solve clinical problems from a range of perspectives and synthesize multiple sources of knowledge. Narrative pedagogy was the framework for a digital story assignment for a senior-level synthesis and clinical decision making course. This article describes how the use of digital stories enhanced students' clinical thinking strategies from a narrative pedagogy perspective.