Bias in team decision-making for advanced heart failure therapies: model application.

Bias in advanced heart failure therapy allocation results in inequitable outcomes for minoritized populations. The purpose of this study was to examine how bias is introduced during group decision-making with an interprofessional team using Breathett's Model of Heart Failure Decision-Making. This was a secondary qualitative descriptive analysis from a study focused on bias in advanced heart failure therapy allocation. Team meetings were recorded and transcribed from four heart failure centers. Breathett's Model was applied both deductively and inductively to transcripts (n = 12). Bias was identified during discussions about patient characteristics, clinical fragility, and prior clinical decision-making. Some patients were labeled as "good citizens" or as adherent/non-adherent while others benefited from strong advocacy from interprofessional team members. Social determinants of health also impacted therapy allocation. Interprofessional collaboration with advanced heart failure therapy allocation may be enhanced with the inclusion of patient advocates and limit of clinical decision-making using subjective data.

Microaggressions in Nursing.

How to address these behaviors to promote health equity and inclusion.

Incivility in the Online and Hybrid Learning Environment During the COVID-19 Pandemic Era.

ABSTRACT: With the surge in online learning since the onset of the COVID-19 pandemic, fostering civil behavior in this environment is essential. This mixed-methods study examined online incivility among faculty and students at two schools of nursing using a quantitative survey instrument with several open-ended questions addressing the impact of the pandemic. Survey results suggested that faculty ( n = 23) and students ( n = 74) experienced a low frequency of online incivility that remained potentially disruptive. Qualitative analyses suggested that the pandemic placed considerable strain on nursing faculty and students while providing increased flexibility for working and learning.

Overcoming waves of helplessness: The meaning of experiencing fear of falling.

Fear of falling (FOF) is prevalent among older adults. While the phenomenon has been conceptually defined and the factors associated with FOF are evident in the nursing literature, the deeply personal experience of this fear from the perspective of older adults is often overlooked. The aim of this study was to explore the meaning of experiencing FOF among older adults (N = 4). Each participant was interviewed twice using van Manen's interpretive phenomenological methodology. Four major interpretive themes emerged: Loss of Self, Part of my Existence, Remaining Safe Within the Boundaries of Fear, and The Exhausting Appraisal of Relationships. While the older adults struggled to manage their FOF, a deeper meaning was expressed during a relentless striving for self-preservation. While FOF can be an experience of overwhelming helplessness, the older adults in this study demonstrated personal resiliency, a perspective that is often lacking in the current literature.

A novel approach for assessing bias during team-based clinical decision-making.

Many clinical processes include multidisciplinary group decision-making, yet few methods exist to evaluate the presence of implicit bias during this collective process. Implicit bias negatively impacts the equitable delivery of evidence-based interventions and ultimately patient outcomes. Since implicit bias can be difficult to assess, novel approaches are required to detect and analyze this elusive phenomenon. In this paper, we describe how the de Groot Critically Reflective Diagnoses Protocol (DCRDP) can be used as a data analysis tool to evaluate group dynamics as an essential foundation for exploring how interactions can bias collective clinical decision-making. The DCRDP includes 6 distinct criteria: challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Based on the strength and frequency of codes in the form of exemplar quotes, each criterion was given a numerical score of 1-4 with 1 representing teams that are interactive, reflective, higher functioning, and more equitable. When applied as a coding scheme to transcripts of recorded decision-making meetings, the DCRDP was revealed as a practical tool for examining group decision-making bias. It can be adapted to a variety of clinical, educational, and other professional settings as an impetus for recognizing the presence of team-based bias, engaging in reflexivity, informing the design and testing of implementation strategies, and monitoring long-term outcomes to promote more equitable decision-making processes in healthcare.

Pilot test of a multicomponent implementation strategy for equity in advanced heart failure allocation.

Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using a pretest-posttest design, the strategy included an 8-week multicomponent training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural changes included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by a framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. REs were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included (1) promoting equitable distribution of scarce resources, (2) requiring a change in team members' time investment to correct bias and change the meeting structure, (3) slowing and then accelerating the allocation process, and (4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated the feasibility for organizational and culture changes.

Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group.

Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.

Race and Gender-Based Perceptions of Older Septuagenarian Adults.

Objectives: Older adults face racism, sexism, and ageism. As the U.S. population ages, it is important to understand how the current population views older adults. Methods: Participants recruited through Amazon's Mechanical Turk provided perceptions of older Black and White models' photographs. Using mixed-effect models, we assessed interactions between race and gender of participants and models. Results: Among Participants of Color and White participants (n = 712, 70% non-Hispanic White, 70% women, mean 37.81 years), Black models were perceived as more attractive, less threatening, and sadder than White models, but differences were greater for White participants (race-by-race interaction: attractive p = 0.003, threatening p = 0.009, sad p = 0.016). Each gender perceived their respective gender as more attractive (gender-by-gender interaction p < 0.0001). Male and female participants perceived male models as happier than female models, but differences were greater for male participants (p = 0.026). Irrespective of participant age group, women were perceived as more threatening (p = 0.012). Other perceptions were not significant. Discussion: Participants had few biases toward older Black and White models, while gender biases favored men.

Race and Gender-Based Perceptions of Older Adults: Will the Youth Lead the Way?

BACKGROUND: Older individuals encounter the greatest racial/gender biases. It is unknown whether younger generations, who often lead culture shifts, have racial and gender biases against older populations. METHODS: Using Amazon's Mechanical Turk's crowdsourcing, we identified how an individual's race and gender are associated with perceptions of individuals aged mid-60s. Participants were asked to rate photograph appearances on Likert Scale (1-10). Interactions between participant and photograph race and gender were assessed with mixed effects models. Delta represents rating differences (positive value higher rating for Whites or women, negative value higher rating for African-Americans or men). RESULTS: Among 1563 participants (mean 35 years ± 12), both non-Hispanic White (WP) and all Other race/ethnicity (OP) participants perceived African-American photos as more trustworthy [Delta WP -0.60(95%CI-0.83, - 0.37); Delta OP - 0.51(- 0.74,-0.28), interaction p = 0.06], more attractive [Delta non-Hispanic White participants - 0.63(- 0.97, - 0.29); Delta Other race/ethnicity participants - 0.40 (- 0.74, - 0.28), interaction p < 0.001], healthier [Delta WP -0.31(- 0.53, - 0.08); Delta OP -0.24(- 0.45, -0.03), interaction p = 1.00], and less threatening than White photos [Delta WP 0.79(0.36,1.22); Delta OP 0.60(0.17,1.03), interaction p < 0.001]. Compared with OP, WP perceived African-American photos more favorably for intelligence (interaction p < 0.001). Both genders perceived photos of women as more trustworthy [Delta Women Participants (WmP) 0.50(0.27,0.73); Delta Men Participants(MnP) 0.31(0.08,0.54); interaction p < 0.001] and men as more threatening [Delta WmP -0.84(-1.27, -0.41), Delta MnP - 0.77(- 1.20, - 0.34), interaction p = 0.93]. Compared with MnP, WmP perceived photos of women as happier and more attractive than men (interaction p < 0.001). Compared with WmP, MnP perceived men as healthier than women (interaction p < 0.001). CONCLUSIONS: Among a young generation, older African-Americans were perceived more favorably than Whites. Gender perceptions followed gender norms. This suggests a decline in implicit bias against older minorities, but gender biases persist. Future work should investigate whether similar patterns are observed in healthcare.

Association of Gender and Race With Allocation of Advanced Heart Failure Therapies.

Importance: Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. Objective: To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. Design, Setting, and Participants: In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. Exposure: Randomization to clinical vignettes. Main Outcomes and Measures: Thematic differences in allocation of advanced therapies by patient race and gender. Results: Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. Conclusions and Relevance: This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.

Tangled pasts, healthier futures: Nursing strategies to improve American Indian/Alaska Native health equity.

American Indian/Alaska Native (AI/AN) populations in the United States continue to experience overall health inequity, despite significant improvement in health status for nearly all other racial-ethnic groups over the past 30 years. Nurses comprise the bulk of healthcare providers in the U.S. and are in an optimal position to improve AI/AN health by transforming both nursing education and practice. This potential is dependent, however, on nurses' ability to recognize the distinct historical and political conditions through which AI/AN health inequities have been produced and sustained. Nurse providers, educators, and leaders must in turn recognize how the sustained conditions of marginalization and expropriation that underpin current AI/AN health inequities continue to shape contemporary AI/AN health outcomes. This manuscript builds upon the extant literature of AI/AN historical health policy and utilizes decolonial theorizations of nursing and a cultural safety framework to propose a series of immediately actionable steps for nursing intervention into AI/AN health inequity. Ultimately, we suggest that it is crucial for nurses to collaborate with AI/AN individuals and communities across educational and clinical settings to further refine these approaches in alignment with the disciplinary obligation of promoting social justice within healthcare.

Does Race Influence Decision Making for Advanced Heart Failure Therapies?

Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think-aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (-0.58; 95% CI, -1.15 to -0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

Nurses' Experiences of Establishing Meaningful and Effective Relationships With American Indian Patients in the Cancer Care Setting.

INTRODUCTION: The establishment of caring relationships with racial and ethnic minority populations is challenging for many cancer care nurses. Nurses serving American Indian (AI) patients frequently encounter population-specific issues, yet their experiences are largely unknown. OBJECTIVE: The purpose of this study was to describe the meaning of the AI patient-cancer care nurse relationship from nurses' perspectives. The study included three objectives: (a) to describe the immediate experiences of nurses that have engaged in cancer care relationships with AI patients, (b) to identify the underlying structures of the AI patient-cancer care nurse relationship as described by nurses, and (c) to interpret the meaning of the patient-nurse relationship within the context of AI cancer care experiences. METHODS: This was an interpretive phenomenological study using a hermeneutical process for data collection and analysis of multiple, exploratory interviews. Thematic reduction was completed to explicate the fundamental structures of this particular relationship. Reduction of individually situated themes resulted in seven shared meta-themes including from task to connection; unnerving messaging; we are one; the freedom of unconditional acceptance; attuning and opening; atoning for the past, one moment at a time; and humanizing the inhumane. RESULTS: Nine cancer care nurses participated. Reconstitution of data and reflective writing suggested that the essential meaning of the AI patient-cancer care nurse relationship was expressed in contradictory yet simultaneous patterns for nurses. Nurses sought synchronicity with their AI patients despite their contextual differences and similarities, yet most lacked adequate cultural safety training. Being in relationship provided nurses great purpose within the universal human context of caring. CONCLUSIONS: Results contribute to the development of interventions designed to improve both the AI cancer care experience and the support and training of nurses. The mutually dependent nature of the patient-nurse relationship implies that strengthening and improving support for one entity may in turn positively impact the other.

Looking Inward: Philosophical and Methodological Perspectives on Phenomenological Self-Reflection.

Engaging in early and ongoing self-reflection during interpretive phenomenological research is critical for ensuring trustworthiness or rigor. However, the lack of guidelines and clarity about the role of self-reflection in this methodology creates both theoretical and procedural confusion. The purpose of this article is to describe key philosophical underpinnings, characteristics, and hallmarks of the process of self-reflection in interpretive phenomenological investigation and to provide a list of guidelines that facilitate this process. Excerpts from an interpretive phenomenological study are used to illustrate characteristics of quality self-reflection. The guidelines are intended to be particularly beneficial for novice researchers who may find self-reflective writing to be daunting and unclear. Facilitating use of self-reflection may strengthen both the interpretive phenomenological body of work as well as that of all qualitative research.