Using Performance Improvement Methods to Evaluate Processes for Writing Multiple-Choice Test Questions in the Postlicensure Clinical Environment: A Case Study.

BACKGROUND: This article is the last of a four-part series to guide educators on the construction and evaluation of multiple-choice test items in the post-licensure environment. Previous articles in this series described the problem and the mechanics of test item construction and evaluation. METHOD: A replicable strategy for evaluating the organizational process for constructing multiple-choice test questions is provided. Steps taken to create change are described; work tools are provided. RESULTS: Guidance and training are needed to create multiple-choice test questions. Many educators have not had training in item construction. Educators welcomed training. Personalized mentorship resulted in improvement. Asynchronous learning alone was helpful and well received and improved self-perceived knowledge, yet fell short of achieving competence. CONCLUSION: Voluntary training may not be adequate to assure enculturation of best practices without accountability standards and monitoring. Future research is indicated to assess the situation and provide national standards for adoption within health care organizations. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Qualitative Analysis of Mental Health Stressors Among Pharmacy and Medical Students Between 2009 and 2020.

OBJECTIVE: The primary objective of this study was to identify and compare stressors between pharmacy and medical students that may lead to poor mental health outcomes and decreased quality of professional medical care. METHODS: We used an inductive reflexive thematic analysis to interpret free-text responses from a stress and depression survey administered to pharmacy and medical students between 2009 and 2020 at a single public university. The inductive process involved several steps, including data familiarization, coding, and theme development. Two of the authors independently coded the data and presented their findings to the research team. After reaching a consensus, the data were recoded according to the new interpretation. Theme generation involved grouping codes into overarching ideas that provided a narrative. RESULTS: Five major themes emerged among both cohorts: constant overwhelming pressure, stressors of an interpersonal relationship, internal battle with oneself, financial burden, and postgraduation anxiety and uncertainty. Constant overwhelming pressure, stresses of an interpersonal relationship, and internal battle with oneself were the 3 most frequent themes identified. One notable stressor observed only among pharmacy students was having an internship during their training years. CONCLUSION: Addressing the well-being of pharmacy and medical students early in training is crucial. Despite the different pharmacy and medical school curricula, it was evident that both cohorts faced similar stressors. This study identified specific stressors among pharmacy and medical students that can help health professional programs develop initiatives to support student well-being.

Evaluating the Quality of Multiple-Choice Test Questions in the Postlicensure Environment.

BACKGROUND: Multiple-choice test questions are among the main measures of knowledge used by educators in the postlicensure environment; however, these tests are often constructed in the absence of guidelines or the means to evaluate examination quality after administration. METHOD: Previously, guidance was provided on constructing quality test items. Here we present instruction for professional development specialists to use postadministration test data for an item analysis, providing insight on test flaws and opportunities for iterative examination improvement. RESULTS: The topics of item difficulty, index of discrimination, and distractor analysis are covered for independent analysis, and topics such as reliability are addressed for those who have access to a formal program. CONCLUSION: Three levels of strategies are described: using a learning management system for item analysis, using free open-source software, and using a minimal standards method of evaluating test items. [J Contin Educ Nurs. 2024;55(10):487-492.].

Original Research: Exploring Nurses' Use of Humor in the Workplace: A Thematic Analysis.

BACKGROUND: The nursing work environment is often stressful and can lead to burnout. The use of humor may help nurses adapt and cope. Although most would agree that, in general, humor can help build camaraderie and ease tense situations, little is known about how nurses use humor in their professional lives. PURPOSE: The study's main purpose was to explore how humor is used and perceived by nurses in the workplace. METHODS: A sample of LPNs, RNs, and advanced practice RNs was recruited in the United States. Participants were interviewed via the videoconferencing platform Zoom. Data from the video recordings, audio transcripts, and investigators' field notes were analyzed using reflexive thematic analysis. RESULTS: Sixteen nurses were interviewed about their use of humor, whether intentional or spontaneous, in the workplace. Three main themes were identified: entertainment , influencing others , and well-being . Participants reported using humor with self and others, including patients, families, and colleagues. Reported benefits include emotional regulation, relationship building, and work enjoyment. Some participants noted feeling insecure over when and whether the use of humor was "appropriate." CONCLUSIONS: The results indicate that nurses' use of humor in the workplace had many benefits. Participants reported that humor could relieve tension, create bonds and strengthen relationships, and enhance both learning and work environments. Many recognized that humor can also be maladaptive and harmful, and that sensitivity and caution are part of using humor skillfully. Still, the benefits of humor appear to outweigh the risks. We conclude that humor is a useful tool nurses can and should use to optimize their nursing experience.

Learning from Health Care Counselors' Perspectives on Health Care Worker Distress: A Qualitative Analysis.

Background: Health care provider stress and emotional distress were well documented long before the COVID-19 pandemic, and there is growing data suggesting these have increased in response to the pandemic. The goal of this study was to take advantage of the unique experiences of licensed mental health (MH) clinicians working with health care trainees and clinicians before and during the pandemic to identify how this crisis affected both ongoing as well as new sources of stress. The Healer Education, Assessment and Referral Program (HEAR) provides MH screening, support, and MH referrals to ~19 000 health care students, trainees, staff, and faculty. Since its inception in 2009, the program has been staffed by 4 licensed counseling professionals who have worked both before and since the COVID-19 pandemic. Methods: Qualitative data obtained from semi-structured, 1-hour interviews and a follow-up 1-hour focus group with 4 HEAR counselors was analyzed using reflexive thematic analysis. Results: Several preexisting stressors were amplified during the pandemic: financial concerns; long work hours; exposure to the suffering of illness, death, and dying; bullying; discordant values and moral distress; social inequities; individuals' lack of adaptive coping; and individuals' self-concept as a victim. New stressors included: health care demand greater than the workforce numbers and resources; caretaking for ill family/friends; homeschooling of children; social isolation; experiencing the COVID-19 crisis as a war, fire, or storm; fear of personal illness and death, especially before vaccines; and hopes of a cure with vaccines; followed by perceived opportunities for improvement in leadership response to staff concerns. Conclusion: Authentically responding to staff concerns/ideas, a patient and provider-centered health care culture, grief education and support, and attention to actionable stressors affecting providers' well-being are indicated to meet the amplified and new stressors triggered by the COVID-19 pandemic and sequelae.

Reporting on Neurological Decline as Identified by Hourly Neuroassessments.

ABSTRACT: BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.

A study protocol for the modified interactive screening program plus MINDBODYSTRONG© RCT: A mental health resiliency intervention for nurses.

BACKGROUND: Nurses, the largest workforce in healthcare, are at high risk of depression, anxiety, burnout, and suicidal ideation. Suicide among nurses is higher than the general population. This randomized controlled trial pairs the MINDBODYSTRONG© cognitive-behavioral skills building program with the American Foundation for Suicide Prevention's (AFSP) Modified Interactive Screening Program (mISP) to reduce depression, suicidal ideation, post-traumatic stress, anxiety, and burnout, and improve healthy lifestyle beliefs, healthy lifestyle behaviors, and job satisfaction in nurses with moderate to high risk of suicide. AIMS: This study aims to determine the effects of the mISP combined with the digitized MINDBODYSTRONG© program versus the mISP alone on depression, suicidal ideation, burnout, anxiety, post-traumatic stress, healthy lifestyle beliefs, healthy lifestyle behaviors, and job satisfaction in 364 U.S. nurses. METHODS: A digitized version of MINDBODYSTRONG© combined with the mISP screening and referral platform will be compared to the AFSP mISP alone through a two-arm randomized controlled trial. Follow-up post-intervention data will be collected at week eight and months three, six, and 12. DISCUSSION: If successful, this study's findings could assist nurses who are hesitant to use conventional mental health resources by providing them with confidential aid and learning opportunities to reduce suicidality, depression, anxiety, post-traumatic stress, and burnout and improve healthy lifestyle beliefs, healthy lifestyle behaviors, and job satisfaction. TRIAL/STUDY REGISTRATION: The Ohio State University Protocol Record 2021B0417, Modified Interactive Screening Program Plus MINDBODYSTRONG: A Mental Health Resiliency Intervention for Nurses, is registered and posted at ClinicalTrials.gov Identifier: NCT05582343. First posted date is October 17, 2022.

Clinician Prediction of Survival vs Calculated Prediction Scores in Patients Requiring Extracorporeal Membrane Oxygenation.

BACKGROUND: Determining appropriate extracorporeal membrane oxygenation (ECMO) candidacy ensures appropriate utilization of this costly resource. The current ECMO survival prediction scores do not consider clinician assessment of patient viability. This study compared clinician prediction of survival to hospital discharge versus prediction scores. OBJECTIVES: The aim of this study was to compare clinician prediction of patients' survival to hospital discharge versus prognostic prediction scores (Respiratory ECMO Survival Prediction [RESP] or Survival After Veno-Arterial ECMO [SAVE] score) to actual survival. METHODS: This was an observational descriptive study from January 2020 to November 2021 conducted with interviews of nurses, perfusionists, and physicians who were involved during the initiation of ECMO within the first 24 hours of cannulation. Data were retrieved from the medical record to determine prediction scores and survival outcomes at hospital discharge. Accuracy of clinician prediction of survival was compared to the RESP or SAVE prediction scores and actual survival to hospital discharge. RESULTS: Accurate prediction of survival to hospital discharge for veno-venous ECMO by nurses was 47%, 64% by perfusionists, 45% by physicians, and 45% by the RESP score. Accurate predictions of patients on veno-arterial ECMO were correct in 54% of nurses, 77% of physicians, and 14% by the SAVE score. Physicians were more accurate than the SAVE score, P = .021, and perfusionists were significantly more accurate than the RESP score, P = .044. There was no relationship between ECMO specialists' years of experience and accuracy of predications. CONCLUSION: Extracorporeal membrane oxygenation clinicians may have better predictions of survival to hospital discharge than the prediction scores. Further research is needed to develop accurate prediction tools to help determine ECMO eligibility.

The Association of Psychotherapy With Burnout, Depression, and Measures of Well-Being in Residents and Fellows: A Pilot Study.

PURPOSE: Resident physicians experience high rates of burnout and depression but rarely prioritize their well-being or seek mental health care. The Accreditation Council for Graduate Medical Education mandated that training programs prioritize resident wellness and emotional and mental health to ensure readily available and accessible mental health care. To help meet that requirement and circumvent barriers to accessing care, the University of California San Diego Healer Education Assessment & Referral (HEAR) Program offers residents and fellows short-term therapy for coping with challenges that threaten their well-being. This report describes the results of a pilot study designed to evaluate the feasibility and effectiveness of the HEAR Program's resident therapy program. METHOD: The cohort included residents and fellows who completed at least 1 postbaseline assessment from January to May 2022. Measures of fulfillment, burnout, self-compassion, quality of life, depression, and suicidal ideation were assessed and compared before and up to 12 weeks after enrollment. RESULTS: Of the 39 residents who consented to participation, 30 completed at least 1 postbaseline assessment. Most outcomes improved after therapy, with significant increases in fulfillment (mean [SE] coefficient, 0.24 [0.08]; z score, 2.86; P = .004), self-compassion (mean [SE] coefficient, 0.37 [0.07]; z score, 5.72; P < .001), and quality of life ( P < .001) and significant reductions in burnout (Stanford burnout scale: mean [SE] coefficient, -0.27 [0.07]; z score, -4.01; P < .001; single-item burnout scale: mean [SE] coefficient, -0.34 [0.08]; z score, -4.37; P < .001) and depression severity (mean [SE] coefficient, -1.08 [0.25]; z score, -4.36; P < .001). CONCLUSIONS: This pilot study noted improvements in fulfillment, compassion, quality of life, and function, as well as reductions in burnout and depression severity, among resident physicians. Future studies in larger cohorts are needed to validate these findings and inform further optimization of this program.

Fostering Psychological Safety and Supporting Mental Health Among Cardiovascular Health Care Workers: A Science Advisory From the American Heart Association.

The psychological safety of health care workers is an important but often overlooked aspect of the rising rates of burnout and workforce shortages. In addition, mental health conditions are prevalent among health care workers, but the associated stigma is a significant barrier to accessing adequate care. More efforts are therefore needed to foster health care work environments that are safe and supportive of self-care. The purpose of this brief document is to promote a culture of psychological safety in health care organizations. We review ways in which organizations can create a psychologically safe workplace, the benefits of a psychologically safe workplace, and strategies to promote mental health and reduce suicide risk.

Organizational Climate for Inclusion Among Nurses: A Mixed-Methods Analysis.

OBJECTIVE: The aim of this study was to answer the research question: What factors predict sense of belonging among nurses?The connection between inclusion (an element of diversity and equity) and a nurse's sense of belonging is poorly understood. METHODS: In this mixed-methods research, regression analysis of Climate for Inclusion Scale subscales and Sense of Belonging score plus thematic content analysis of questions assessing sense of belonging were conducted. Nurses (n = 131) attending a research conference in June to July 2022 were invited to participate; 131 (72%) participated. RESULTS: Climate for Inclusion Scale was positively associated with and predictive of sense of belonging (F3,113 = 71.7, P < 0.001). Themes reflecting actions to enhance sense of belonging were as follows: authentic leadership, embracing social justice, team unification, feeling heard, being seen, professional development, developing a healthier work environment, and integration of differences. CONCLUSIONS: Leaders can promote a sense of belonging among nurses by focusing on actions reflected in the themes.

An Evidence-Based Approach to Constructing Multiple-Choice Test Questions for Knowledge Assessment.

BACKGROUND: This article provides nursing educators practical tips and evidence-based strategies for effective construction of multiple-choice questions (MCQs). Well-designed MCQs that align with the intended learning objectives are critical for implementing sound assessment practices. METHOD: This article offers a step-by-step approach to test construction, starting with the assessment blueprint and followed by important considerations when writing the specific components of the MCQ. RESULTS: Appropriate inclusion of clinical context in the MCQ and a description of common flaws to avoid, with suggested remedies, are also addressed. CONCLUSION: Ultimately, the goal of this article is to equip nurse educators with the foundational tools to create high-quality MCQs that effectively assess knowledge acquisition by learners. [J Contin Educ Nurs. 2024;55(6):289-296.].

Development and Validation of an ICU Delirium Playbook for Provider Education.

Although delirium detection and prevention practices are recommended in critical care guidelines, there remains a persistent lack of effective delirium education for ICU providers. To address this knowledge-practice gap, we developed an "ICU Delirium Playbook" to educate providers on delirium detection (using the Confusion Assessment Method for the ICU) and prevention. DESIGN: Building on our previous ICU Delirium Video Series, our interdisciplinary team developed a corresponding quiz to form a digital "ICU Delirium Playbook." Playbook content validity was evaluated by delirium experts, and face validity by an ICU nurse focus group. Additionally, focus group participants completed the quiz before and after video viewing. Remaining focus group concerns were evaluated in semi-structured follow-up interviews. SETTING: Online validation survey, virtual focus group, and virtual interviews. SUBJECTS: The validation group included six delirium experts in the fields of critical care, geriatrics, nursing, and ICU education. The face validation group included nine ICU nurses, three of whom participated in the semi-structured feedback interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 44-question quiz had excellent content validity (average scale-level content validity index [S-CVI] of individual items = 0.99, universal agreement S-CVI = 0.93, agreement κ ≥ 0.75, and clarity p ≥ 0.8). The focus group participants completed the Playbook in an average (sd) time of 53 (14) minutes, demonstrating significant improvements in pre-post quiz scores (74% vs 86%; p = 0.0009). Verbal feedback highlighted the conciseness, utility, and relevance of the Playbook, with all participants agreeing to deploy the digital education module in their ICUs. CONCLUSIONS: The ICU Delirium Playbook is a novel, first-of-its-kind asynchronous digital education tool aimed to standardize delirium detection and prevention practices. After a rigorous content and face validation process, the Playbook is now available for widespread use.

A randomised controlled trial of a nutrition and a decision support intervention to enable partnerships with families of critically ill patients.

AIMS AND OBJECTIVES: The aim of the study was to investigate the effect of supporting family members to partner with health professionals on nutrition intakes and decision-making and to evaluate intervention and study feasibility. BACKGROUND: Family partnerships can improve outcomes for critically ill patients and family members. Interventions that support families to engage with health professionals require evaluation. DESIGN: A multi-centre, randomised, parallel group superiority Phase II randomised controlled trial. METHODS: In nine intensive care units (ICUs) across three countries, critically ill patients ≥60 years, or those 55-59 years with advanced chronic diseases and expected ICU length of stay >72 h and their family member were enrolled between 9 May 2017 and 31 March 2020. Participants were randomised (1:1:1) to either a decision support or nutrition optimisation family-centred intervention, or usual care. Primary outcomes included protein and energy intake during ICU and hospital stay (nutrition intervention) and family satisfaction (decision support). Study feasibility was assessed as a composite of consent rate, intervention adherence, contamination and physician awareness of intervention assignment. RESULTS: We randomised 135 patients/family members (consent rate 51.7%). The average rate of randomisation was 0.5 (0.13-1.53) per month. Unavailability (staff/family) was the major contributor to families not being approached for consent. Declined consent was attributed to families feeling overwhelmed (58/126, 46%). Pandemic visitor restrictions contributed to early study cessation. Intervention adherence for the decision support intervention was 76.9%-100.0% and for the nutrition intervention was 44.8%-100.0%. Nutritional adequacy, decisional conflict, satisfaction with decision-making and overall family satisfaction with ICU were similar for all groups. CONCLUSIONS: Active partnerships between family members and health professionals are important but can be challenging to achieve in critical care contexts. We were unable to demonstrate the efficacy of either intervention. Feasibility outcomes suggest further refinement of interventions and study protocol may be warranted. RELEVANCE TO CLINICAL PRACTICE: Interventions to promote family partnerships in critical illness are needed but require a greater understanding of the extent to which families want and are able to engage and the activities in which they have most impact. REPORTING METHOD: This study has been reported following the Consolidated Standards of Reporting Trials (CONSORT) and the Template for Intervention Description and Replication (TIDieR) guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients and caregivers were engaged in and contributed to the development and subsequent iterations of the two family-centred interventions use in this study. CLINICAL TRIAL REGISTRATION NUMBER: Trial registration. CLINICALTRIALS: gov, ID: NCT02920086. Registered on 30 September 2016. First patient enrolled on 9 May 2017 https://clinicaltrials.gov/ct2/results?cond=&term=NCT02920086&cntry=&state=&city=&dist=.

American Academy of Nursing Expert Panel Consensus Statement on leveraging equity in policy to improve recognition and treatment of mental health, substance use disorders, and nurse suicide.

Rates of nurse mental health and substance use disorders are high. Heightened by the COVID-19 pandemic, nurses are challenged to care for patients in ways that often jeopardize their own health and increase risks for their families. These trends exacerbate the epidemic of suicide in nursing underscored by several professional organization clarion calls to nurses' risk. Principles of health equity and trauma-informed care dictate urgent action. The purpose of this paper is to establish consensus among clinical and policy leaders from Expert Panels of the American Academy of Nursing about actions to address risks to mental health and factors contributing to nurse suicide. Recommendations for mitigating barriers drew from the CDC's 2022 Suicide Prevention Resource for Action strategies to guide the nursing community to inform policy, education, research, and clinical practice with the goals of greater health promotion, risk reduction, and sustainment of nurses' health and well-being are provided.

A deductive thematic analysis of nurses with job-related problems who completed suicide during the early COVID-19 pandemic: A preliminary report.

BACKGROUND: Prior to the novel coronavirus (COVID-19) pandemic, nurses died by suicide more frequently than the general population. Antecedents prior to death include known job problems, such as disciplinary action; diversion of medications; inability to work due to chronic pain; and physical and mental illness. AIM: The aim of this study was to explore the suicide experience of nurses who died with known job-related problems during the early phase of the COVID-19 pandemic compared to what has been previously described. METHOD: Deductive reflexive thematic analysis was used to analyze narratives of nurses with known job problems who died by suicide from the Centers for Disease Control and Prevention's National Violent Death Reporting System. RESULTS: Forty-three nurses with known job-related problems completed suicide between March and December 2020. Factors associated with death were similar to previous findings with notable exceptions, increased prevalence of suicidal ideation and post-traumatic stress prior to the event. Pandemic-specific issues were noted including reduction in hours, fear of disease transmission, civil unrest, and grief-related trauma. LINKING EVIDENCE TO ACTION: Suicide prevention programs need to address both institutional and individual factors associated with nurse suicide. As previously recommended, transitions into retirement and job loss are vulnerable times warranting psychological support. Further, strategies to reduce the impact of stressors and increase support for nurses are needed at the organizational level. A systems level approach to hardwire coping strategies is indicated pre-licensure and throughout nurses' careers. A new focus on how to process personal and professional grief is warranted. Resources are needed for nurses traumatized by life (rape, childhood trauma) or work-related experiences.

Reflexive thematic analysis of job-related problems associated with pharmacist suicide, 2003-2019.

BACKGROUND: Few qualitative studies have focused on suicide and specific job-related problems associated with suicide in pharmacists. Greater knowledge of specific work-related stressors amongst pharmacists could inform suicide prevention strategies. OBJECTIVE: To identify job-related stressors associated with pharmacist suicides and compare stressors to those previously reported in physicians and nurses. METHODS: Free-text law enforcement and medical examiner data for pharmacist suicides were extracted from the National Violent Death Registry (NVDRS) for 2003-2019. Reflexive thematic analysis was deployed via a deductive approach utilizing codes and themes found in previous research on nurse and physician suicides. New codes were also identified through inductive coding. RESULTS: A total of 291,872 suicides occurred between 2003 and 2019, of which 392 were pharmacist deaths. Of these, 62 pharmacist suicides were coded with job-related problems. Almost all deductive themes/codes extracted from nurses and physicians were present in pharmacists. Common codes found in the pharmacist dataset that were also found previously in physicians and nurses were: history of mental health, substance use disorder, hopelessness impending or proceeding job loss, and access to lethal weapons and/or drugs. Novel codes were added through inductive content analysis. Codes novel to pharmacists were: verbalized suicidal ideation (SI) or intent, diversion for the purpose of suicide, and the fear of job loss. Disciplinary action at the institutional level was associated with the fear of job loss and cited as the event triggering suicide completion. CONCLUSION: Pharmacists have similar job-related stressors associated with suicide as physicians and nurses. Evaluating the process of disciplinary action is warranted. Future research is indicated to evaluate causal relationship between work-related stressors and mental health outcomes leading to suicide in pharmacists.