Accounting for taste: preferences mediate the relationship between documentation time and ambulatory physician burnout.

OBJECTIVES: Physician burnout in the US has reached crisis levels, with one source identified as extensive after-hours documentation work in the electronic health record (EHR). Evidence has illustrated that physician preferences for after-hours work vary, such that after-hours work may not be universally burdensome. Our objectives were to analyze variation in preferences for after-hours documentation and assess if preferences mediate the relationship between after-hours documentation time and burnout. MATERIALS AND METHODS: We combined EHR active use data capturing physicians' hourly documentation work with survey data capturing documentation preferences and burnout. Our sample included 318 ambulatory physicians at MedStar Health. We conducted a mediation analysis to estimate if and how preferences mediated the relationship between after-hours documentation time and burnout. Our primary outcome was physician-reported burnout. We measured preferences for after-hours documentation work via a novel survey instrument (Burden Scenarios Assessment). We measured after-hours documentation time in the EHR as the total active time respondents spent documenting between 7 pm and 3 am. RESULTS: Physician preferences varied, with completing clinical documentation after clinic hours while at home the scenario rated most burdensome (52.8% of physicians), followed by dealing with prior authorization (49.5% of physicians). In mediation analyses, preferences partially mediated the relationship between after-hours documentation time and burnout. DISCUSSION: Physician preferences regarding EHR-based work play an important role in the relationship between after-hours documentation time and burnout. CONCLUSION: Studies of EHR work and burnout should incorporate preferences, and operational leaders should assess preferences to better target interventions aimed at EHR-based contributors to burnout.

Building a research-focused academic practice partnership: A stepwise approach.

The 20th century began a period of reform in nursing education and practice, with more nurses receiving advanced degrees and serving in key leadership roles throughout healthcare organizations. During this period, the transformation of the healthcare delivery system encouraged innovation and collaboration between academic nursing programs and other healthcare entities to develop partnerships based on a shared vision and goals. As a result, nurses are negotiating academic-practice partnership agreements and leading interprofessional teams to meet the needs of collaborating organizations. This article describes a stepwise approach to building a research-focused academic practice partnership, from a needs assessment to an evaluation of the partnership.

Academic-Practice Partnership to Prevent and Manage Pressure Injuries: An Evidence-Based Quality Improvement Initiative.

PURPOSE: This evidence-based quality improvement (EBQI) initiative examined the effect of an academic-practice (A-P) partnership on improvement in quality measures in an acute care setting, specifically hospital-acquired pressure injury (HAPI) prevention and management. DESIGN: A pre-/postdescriptive design was conducted using the practice-informed active learning program to guide the project. PARTICIPANTS AND SETTING: The EBQI initiative was conducted at a Southern Gulf-Coast university college of nursing and clinical nursing practice leaders at its affiliated 406-bed academic health center/level I trauma center, regional burn center, and comprehensive stroke center. Both institutions are located in the Southeastern United States (Mobile, Alabama). METHODS: The A-P council used a participatory action research approach and developed a practice-informed active learning program incorporating Melnyk's evidence-based practice (EBP) steps, the Donabedian Model and the Patient-Centered Outcomes Research Institute (PCORI) Stakeholder Engagement in Question Development and Prioritization (SEED). METHOD: Hospital-acquired pressure injuries were selected as the quality outcome to address. To identify HAPI prevention/management evidenced-based practices, the A-P council conducted an integrative literature review and developed a concept map and the Pressure Injury Prevention Gap Analysis Instrument. The gap analysis identified significant gaps between EBP and current pressure injury prevention practices, with priority ranking of gaps for action by key stakeholders. OUTCOME: Following the practice-informed active learning program objectives, the A-P council identified 79 HAPI best EBPs organized by Donabedian domains of structure, process, and outcome and prioritized 3 gaps for action. Actions to address the HAPI gaps included: restructuring the hospital HAPI program, incorporating appropriate leadership to guide the HAPI program, modifying the HAPI reporting process, hiring specialized experts (WOC nurses) with emphasis on pressure injury prevention, establishing a standardized HAPI prevalence survey, improving electronic documentation, increasing transparency of HAPI reporting, improving HAPI accountability at the unit level, and exploring technology to enhance skin assessment. While HAPIs increased by 6.3% from 2019 (n = 104) to 2021 (n = 111), HAPI severity (Stages 3 and 4) decreased by 9.9% from 2019 (n = 14, or 13.46%) to 2021 (n = 4, or 3.6%). IMPLICATIONS FOR PRACTICE: Our experience with this quality improvement initiative indicates that an A-P partnership can provide a model to address complex clinical problems, quality indicators, and quality improvement while advancing a culture of inquiry and scholarship and building nursing capacity.

Fostering resilience in young people with intellectual disabilities using a 'settings' approach.

The need to foster resilience amongst young people with intellectual disabilities is increasingly recognised within policy. Critically, understanding of the actual means by which this aspiration might be most sensitively and effectively met is considered weak. This paper reports on an exploratory case-study of a social enterprise community café - The Usual Place - that through the promotion of employability, seeks to promote resilience amongst its young 'trainees' with intellectual disabilities. Two research questions were set: "how is 'resilience' conceptualized within the organisation" and "what features within the organisation are significant in fostering resilience"? We identify a range of significant features associated with being able to successfully foster resilience - the need for a foundational 'whole organisation'(settings) approach based on high levels of participation and choice; the negotiation of a constructive dynamic tension between 'support' and 'exposure'; and the embedding of these actions in embodied actions and day-to-day organisational activities.

Scribes with PGY-1 Residents on Inpatient Medicine Teams: Effect on Time Spent in Meaningful Work.

Background: The high documentation demands and limited time in direct patient care in the first year of internal medicine residency represent concerns for burnout and low job satisfaction in this important year of training. Objective: To assess the effect of scribes on the time PGY-1 residents spent on various work tasks. Methods: Participants were 24 PGY-1 internal medicine residents on two inpatient medicine teams at one site for 6 months (September 2019-February 2020). Residents were assigned a scribe during the first or second 2 weeks of a 4-week rotation and had no scribe for the other 2 weeks. Time study observers documented resident work activities. Residents ranked the meaningfulness of work activities via survey at the end of each 2-week period. Results: Of 24 residents, 18 (75%) completed the survey at both time points. Residents ranked patient care as the most meaningful and EHR work as the least meaningful work activity. EHR work claimed the largest percentage of time, with or without a scribe (mean, 33.2% and 39%, respectively). With a scribe, residents spent significantly less time (-5.8%, P < 0.0001) in EHR work and significantly more time (1.3%, P = 0.0267) in direct patient care and coordinating patient care (3.0%, P < 0.0001). Conclusions: The presence of a scribe with PGY-1 internal medicine residents on inpatient teams resulted in a significantly greater percentage of total work time spent in work they considered most meaningful and a significantly lower percentage of total work time in work they considered least meaningful.

Effects of the Perceived Risk of Contracting COVID-19 on Nursing Students' Well-Being.

BACKGROUND: Although mental health symptoms increased during the coronavirus disease 2019 (COVID-19) pandemic, little is known about the associations between nursing students' perceived risk of contracting COVID-19 and their academic and psychological well-being. This study examined associations between perceived COVID-19 risk, likelihood of completing nursing education, and mental health factors of nursing students. METHOD: A total of 979 nursing students completed self-report measures of perceived COVID-19 risk, anticipated academic completion, anxiety and depressive symptoms, stress, coping self-efficacy, hope, and social support. RESULTS: Students with higher perceived COVID-19 risk reported increased anxiety and depression as well as decreased likelihood of graduating, coping self-efficacy, and levels of social support. CONCLUSION: Findings indicate the need for increased mental health support for nursing students for successful completion of their programs. Educators should increase support and proactively strengthen positive psychology factors to mitigate the effects of COVID-19 and other crises on nursing students' well-being. [J Nurs Educ. 2022;61(11):641-645.].

Eliminated routine postorthotopic liver transplant antibiotics in uncomplicated patients leads to equivalent safety outcomes.

Objective: The purpose of this retrospective study was to evaluate safety and efficacy end points of a postoperative antibiotic prophylaxis protocol in liver transplant (LT) patients, which was revised to limit antibiotic use. Methods: In the routine antibiotics group (RA), patients routinely received prophylactic antibiotics for around 3 days postoperatively for a variety of rationales, versus the limited antibiotics group (LA), in which patients received antibiotics for the treatment of secondary peritonitis. Patients were included if they were 18 or older and underwent liver transplant between January 2016 and September 2019. In total, 216 patients remained after exclusion: 118 patients in the RA group and 98 patients in the LA group. Results: We detected a significant difference in the primary end point of postoperative antibiotic days of therapy. The median days of therapy was 2 for the RA group and 0 for the LA group (P < 0.005). Significantly fewer patients received only intraoperative antibiotics in the RA group versus the LA group: 42 (35.6%) versus 76 (73.5%) respectively (P < .005). There was no significant difference in secondary or safety outcomes, including surgical site infections. Conclusions: This study provides evidence that limiting the duration of prophylactic antibiotics postoperatively and treating most patients with only intraoperative antibiotics is safe.

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat.

As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders.

Reducing Shame, Promoting Dignity: A Model for the Primary Prevention of Complex Post-Traumatic Stress Disorder.

Complex post-traumatic stress disorder (CPTSD) refers to the complex psychological and psychosocial sequelae caused by prolonged interpersonal abuse. Contemporary approaches to CPTSD are dominated by individualized psychological interventions that are long term and costly. However, accumulating evidence indicates that CPTSD is a high prevalence mental illness implicated in significant social problems, with a pattern of lateral and intergenerational transmission that impacts on already disadvantaged communities. Consequently, there have been calls for a public health model for the prevention of CPSTD; however, there has been a lack of clarity as to what this should entail. This article argues that empirical and conceptual shifts framing CPTSD as a shame disorder offers new preventative opportunities. The article presents a series of interconnected literature reviews including a review of available prevalence data on CPTSD, the public health implications of CPTSD, the role of shame and humiliation in CPTSD, and current scholarship on dignity in public policy and professional practice. Drawing on these reviews, this article develops a social ecological model of primary prevention to CPTSD with a focus on the reduction of shame and the promotion of dignity at the relational, community, institutional, and macrolevel. A broad overview of this model is provided with examples of preventative programs and interventions. While the epidemiology of CPTSD is still emerging, this article argues that this model provides the conceptual foundations necessary for the coordination of preventative interventions necessary to reduce to the risk and prevalence of CPSTD.

Undergraduate versus graduate nursing students: Differences in nutrition, physical activity, and self-reported body mass index.

ObjectiveThis study compared self-reported nutrition, physical activity, and body mass index (BMI) in undergraduate versus graduate nursing students.ParticipantsRespondents included 233 undergraduate and 230 graduate nursing students in a Southeastern public university.MethodsThe study was an exploratory, descriptive, cross-sectional comparison administered via online questionnaire including self-reported demographics, nutritional intake, physical activity, and BMI.ResultsUndergraduates reported exercising more than graduate students. Graduate students reported consuming significantly more vegetables than undergraduates; however, more graduate students self-reported BMIs in overweight and obese categories than undergraduates.ConclusionsFindings provide a foundational understanding that interventions or educational programs to improve self-care behaviors of nursing students should be tailored depending on the educational level of the students. Educators must establish self-care skills within nursing students at all levels to help them preserve their health in the fast-paced, strenuous, and stressful work of all echelons of nursing upon completion of the educational program.

Weight Bias and Stigma: Impact on Health.

Weight bias and stigma exist in a variety of realms in our society (media, education, employment, and health care), and unfortunately many view it as a socially acceptable form of discrimination. Patients with obesity often avoid scheduling appointments for health promotion visits and routine care due to perceived weight bias and stigma from their health care provider. Within the health care setting, it is important that health care providers strategically focus on reducing obesity bias and provide high-quality obesity management. People-first language should be used and waiting rooms and examination rooms should be accommodating to people of all sizes.

A practical approach to obesity prevention: Healthy home habits.

ABSTRACT: Families have the potential to foster a healthy home environment aimed at reducing the risk of overweight and obesity. Establishing habits associated with reduced risk of obesity and overweight early in childhood can have lasting effects into adulthood. Nurse practitioners can encourage families to participate in healthy habits by addressing areas of growth for obesity prevention within the home. A review of the most recent literature, approximately over the past decade, was used to provide a consolidated source of reference for healthy home habits for the nurse practitioner. The search included terms such as "obesity," "overweight," "healthy habits," "physical activity," "obesogenic behaviors," "family meals," "screen time," "depression," "sugary beverages," and "portion sizes." The information was synthesized into three content areas: nutrition and consumption, patterns of activity, and stress within the home. Establishing healthy habits early in life can protect against the development of overweight and obesity. Nurse practitioners can serve a vital role in the prevention of pediatric, adolescent, and adult obesity. Equipped with the unique role of assisting those from a diverse patient base, nurse practitioners can inform patients how to improve healthy habits to decrease the likelihood of obesity or overweight. Encouraging behavior change related to the healthy habits associated with the prevention of overweight and obesity can have a long-term impact on the health of an entire family.

Longitudinal whole-genome based comparison of carriage and infection associated Staphylococcus aureus in northern Australian dialysis clinics.

BACKGROUND: The study objective was to reveal reservoirs potentially leading to Staphylococcus aureus infections in haemodialysis clinic clients in the tropical north of the Australian Northern Territory (NT). This client population are primarily Aboriginal Australians who have a greater burden of ill health than other Australians. Reservoir identification will enhance infection control in this client group, including informing potential S. aureus decolonisation strategies. METHODS AND FINDINGS: The study participants were 83 clients of four haemodialysis clinics in the Darwin region of the NT, and 46 clinical staff and researchers who had contact with the clinic clients. The study design was longitudinal, encompassing swabbing of anatomical sites at two month intervals to yield carriage isolates, and also progressive collection of infection isolates. Swab sampling was performed for all participants, and infection isolates collected for dialysis clients only. Analysis was based on the comparison of 139 carriage isolates and 27 infection isolates using whole genome sequencing. Genome comparisons were based on of 20,651 genome-wide orthologous SNPs, presence/absence of the mecA and pvl genes, and inferred multilocus sequence type and clonal complex. Pairs of genomes meeting the definition of "not discriminated" were classed as defining potential transmission events. The primary outcome was instances of potential transmission between a carriage site other than a skin lesion and an infection site, in the same individual. Three such instances were identified. Two involved ST762 (CC1) PVL- MRSA, and one instance ST121 PVL+ MSSA. Three additional instances were identified where the carriage strains were derived from skin lesions. Also identified were six instances of potential transmission of a carriage strains between participants, including transmission of strains between dialysis clients and staff/researchers, and one potential transmission of a clinical strain between participants. There were frequent occurrences of longitudinal persistence of carriage strains in individual participants, and two examples of the same strain causing infection in the same participants at different times. Strains associated with infections and skin lesions were enriched for PVL and mecA in comparison to strains associated with long term carriage. CONCLUSIONS: This study indicated that strains differ with respect to propensity to stably colonise sites such as the nose, and cause skin infections. PVL+ strains were associated with infection and skin lesions and were almost absent from the carriage sites. PVL- MRSA (mainly CC1) strains were associated with infection and also with potential transmission events involving carriage sites, while PVL- MSSA were frequently observed to stably colonise individuals without causing infection, and to be rarely transmitted. Current clinical guidelines for dialysis patients suggest MRSA decolonisation. Implementation in this client group may impact infections by PVL- MRSA, but may have little effect on infection by PVL+ strains. In this study, the PVL+ strains were predominant causes of infection but rarely colonised typical carriage sites such as the nose, and in the case of ST121, were MSSA. The important reservoirs for infection by PVL+ strains appeared to be prior infections.

Characteristics of Negative and Positive Mental Health Among Nursing Students in the United States.

BACKGROUND: Researchers have documented significant psychological problems among nursing students, but findings have been inconclusive as to whether nursing students are "at-risk" for mental health problems compared with their non-nursing peers. AIMS: This study examined whether nursing students have unique mental health characteristics compared with students from other professions. METHOD: Undergraduates (N = 18,312; nursing n = 1,399) were selected from the 2016-2017 National Healthy Minds Study. Participants completed the Patient Health Questionnaire-9 (depression), the Generalized Anxiety Disorder-7 (anxiety), and the Flourishing Scale (positive psychology). RESULTS: Nursing students were equally likely to screen positive for depression and anxiety compared with their non-nursing peers. However, when controlling for gender, age, and year in school, multigroup structural equation modeling analyses revealed that female (but not male) nursing students reported significantly higher levels of specific anxiety symptoms and certain psychological strengths than female students from other professions. Nursing students are equally likely to screen positive for depression or anxiety as their non-nursing peers; however, anxiety disorders may reflect symptom profiles unique to nursing students. CONCLUSIONS: Findings suggest a need for tailored screening and interventions to reduce mental health problems and harness psychological strengths unique to nursing students.

An internal medicine residency's response to the COVID-19 crisis: caring for our residents while caring for our patients.

BACKGROUND: In response to the COVID-19 pandemic, internal medicine residencies have had to develop new teaching strategies and attend to wellness concerns. Providing front-line care for patients in a time of widespread crisis while maintaining attention to training has created unprecedented challenges. OBJECTIVE: Our large community hospital based internal medicine residency sought to develop and evaluate a crisis response to the demands of the COVID-19 pandemic to meet our residents' educational and wellness needs. METHODS: In March 2020, our residency developed a crisis plan for functioning during the COVID-19 pandemic. A brief survey was sent via email to our 149 residents to obtain their evaluation of how well their needs were being met by this response. RESULTS: 92 (62%) residents completed the survey. 88% indicated their well-being needs were well met. Other components were also rated as successful: effective communication (86%), scheduling/staffing (78%), preparing residents for clinical service (77%), and educational needs (76%). CONCLUSIONS: Our residency crisis response to the COVID-19 pandemic was favorably evaluated by our residents in meeting their training and well-being needs. In future work we plan to seek longer-term and more objective measures to assess how residents fare during these challenging times, and to use lessons learned to prepare for future crisis situations.

Nursing students' resilience, depression, well-being, and academic distress: Testing a moderated mediation model.

AIM: Academic distress is a leading cause of attrition among nursing students. The present study tested a positive psychology-oriented model detailing the potential links between nursing students': (a) psychological resilience; (b) depressive symptoms; (c) intrapersonal well-being; (d) interpersonal well-being; and (e) academic distress. Additionally, we tested whether the academic benefits of resilience were conditional upon nursing students' perceptions of their campus climate as supportive of mental health and well-being. DESIGN: A correlational, cross-sectional design was employed. METHOD: Nursing students (N = 933) were selected from the national 2017-2018 Healthy Minds Study (HMS). Students completed measures of resilience, depressive symptoms, intrapersonal well-being (flourishing), interpersonal well-being (belonging), and academic distress. RESULTS: Conditional process modelling tested depression, belonging, and flourishing as mediators of the associations between resilience and academic distress variables. Furthermore, perceptions of campus climate were included as potential moderators of these mediation effects. Results indicated that the protective academic benefits of resilience were primarily explained by decreases in depression but that this effect was strongest for nursing students with negative perceptions of their campus climate. CONCLUSION: Findings highlight the psychological and academic benefits of greater resilience and the moderated mediation results suggest that such benefits were conditional on the broader campus climate. IMPACT: Nurse educators and policymakers should consider addressing contextual factors, such as campus climate, in addition to resilience training in their efforts to reduce the negative academic impacts of mental health problems and stress in nursing school.

Table Quizzes as an Assessment Tool in the Gross Anatomy Laboratory.

Using cadaveric instruction in a graduate-level anatomy course is an expensive and time-consuming undertaking. While this is a worthwhile endeavor, most first-year medical students and students in the health fields struggle with the independent, self-directed learning approach in the cadaveric laboratory, and going beyond rote memorization of the material. As such, effective assessment tools that maximize student learning in the cadaveric laboratory are critical, especially if no lecture component is present. Dissection quality often reflects student attention to detail and therefore may be tied to overall performance in the course. The aim of this study was to investigate the relationship between weekly table quizzes and the overall student outcomes in a graduate biomedical human dissection class as well as examining the benefits and implications of this approach. In this course, a uniquely structured weekly quiz assessed dissection quality and probed student understanding in human anatomy. Student data compiled from 5 years of dissection courses were analyzed to evaluate the relationship between performance in the weekly assessment and on the unit examinations. The results showed a statistically significant relationship between the weekly quizzes and the student examinations at the end of each dissection block in 2013, 2015, 2016, and 2017. The data suggest a potential correlation between performance on weekly quizzes and on unit examinations. The unique nature of the table quizzes provides the students with the opportunity to practice the retrieval of their knowledge, feel more guided throughout their dissection, and receive immediate feedback on their performance. This assessment tool also provides a way to predict student outcomes and an opportunity for early intervention to help at-risk students. The analysis of this research study contributes to the need for more data on the usage of assessment tools in a graduate human dissection class.

Sleep, screen time, and family meal frequency in preschool children: A pilot study.

This exploratory pilot study identified the prevalence and perceptions of three healthy habits in preschool-age children by surveying their parents/caregivers. Researchers examined children's hours of sleep, screen time, and number of family meals per week.

Nurse practitioner students' observations of preceptor engagement in obesity management and weight bias: A mixed-methods approach.

BACKGROUND: Obesity is considered a growing epidemic in the United States. Nurse practitioners (NPs) have the opportunity to serve as leaders in addressing concerns related to disease management, particularly obesity. Currently, we lack an awareness of how NP students are learning obesity management from their preceptors. PURPOSE: Thus, the current study sought to explore how NP students perceive preceptors' behaviors when managing patients with obesity. METHODOLOGICAL ORIENTATION: This study used a mixed-methods design. Participants were asked to report how often they observed their preceptors engage in different strategies when interacting with patients with obesity (e.g., calculate body mass index, identify goals). Students were then asked to respond to the statement: "share observations you made of how patients with obesity were treated in this environment." Students completed 2 clinical rotations during this period and, thus, were asked to answer the questions twice to capture experiences at both clinical sites. SAMPLE: Researchers surveyed 225 NP students completing clinical rotations in 3 settings (Family Practice, Pediatrics, and Obstetrics/Gynecology). CONCLUSIONS: Quantitative results revealed significant differences in the frequency of observed obesity management behaviors by all preceptors. Qualitative results revealed that NP students most often observed preceptors displaying interpersonal warmth without weight bias when working with patients with obesity. Contrary to current literature, this sample of NP students observed their preceptors engaging in positive interactions with individuals with obesity. IMPLICATIONS FOR PRACTICE: Educators must continue to teach students to engage in unbiased behavior toward patients. It is critical to continue to improve obesity management content offered in NP programs.