A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural dexterity Training for Surgeons (PACTS) Trial.

OBJECTIVES: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs. SUMMARY BACKGROUND DATA: Cross-cultural training of providers may reduce healthcare outcome disparities, but its effectiveness in surgical trainees is unknown. METHODS: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between Periods 1 and 2, while the Delayed group ("Delayed") received PACTS between Periods 2 and 3. Residents were assessed pre- and post-intervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. Chi-square and Fisher's exact tests were conducted to evaluate within- and between-intervention group differences. RESULTS: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6% to 88.2%, P<0.0001), Self-Assessed Skills (74.5% to 85.0%, P<0.0001), and Beliefs (89.6% to 92.4%, P=0.0028) improved after PACTS; Knowledge scores (71.3% to 74.3%, P=0.0661) were unchanged. Delayed resident scores pre- to post-PACTS showed minimal improvements in all domains. When comparing the two groups at Period 2, Early residents had modest improvement in all 4 assessment areas, with statistically significant increase in Beliefs (92.4% vs 89.9%, P=0.0199). CONCLUSION: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Knowledge, skills, and attitudes (KSAs) of adaptable academic nurse educators.

AIM: Using the Knowledge, Skills, and Attitudes (KSAs) framework, the aim of this study was to explore the specific knowledge, skills and attitudes of adaptable nurse educators to help inform the preparation of current and future educators for smooth transitions during periods of change. BACKGROUND: External events, such as hurricanes, earthquakes, floods and wildfires can force programs to relocate and suspend classes for several days or weeks. These natural disasters have the potential to have a negative impact on the number of nursing students graduating on time as well as the quality of the clinical education experience and preparation for practice. Many lessons about educator adaptability can be learned from the COVID-19 restrictions. Identifying the KSAs of adaptable nurse educators during the rapidly changing educational landscape provided the opportunity for a foundational needs assessment to guide the preparation of educators for seamless transitions during times of change. DESIGN: To identify the KSA's of adaptable nurse educators, an exploratory qualitative study using focus groups was conducted. The study used thematic analysis. METHODS: The research team developed, and pilot-tested focus group interview questions based on content areas identified in the literature. Targeted questions included queries specific to the KSAs necessary for adaptation and successful teaching using simulation. Educators from pre-licensure nursing programs in the United States participated in one of five 60-minute focus groups held virtually via a secure online meeting platform. RESULTS: Adaptable nurse educators have knowledge of resources, ongoing assessment, evaluation and teaching strategies and an understanding of the skillsets of their colleagues. Their skills include leadership, teamwork, redesigning learning and assessment. They demonstrate qualities such as resilience, empathy, acceptance, openness and positivity. CONCLUSION: With the current nursing workforce crisis, external events cannot be allowed to slow academic progression and graduation from nursing programs. In this exploratory qualitative study using focus groups, the KSAs held by adaptable nurse educators were explored. The findings of this study highlight the importance of collaboration and teamwork in academic institutes. The findings can be used as the foundation for nursing programs to prepare for future external events.

Cultivating Self-Compassion to Protect Nurses From Burnout and Secondary Traumatic Stress.

Nursing burnout, a result of prolonged occupational stress, has always been a challenge in health care, but recently the COVID-19 pandemic made this issue into a national priority. In fact, burnout among health care workers is one of the four priorities of the U.S. Surgeon General. Health care leaders and organizations are eager to implement strategies to improve nurses' well-being and, thus, enhance their mental health. Much of the literature has focused on the antecedents and consequences of nursing burnout, but there is limited information on strategies that protect perinatal nurses from burnout. Self-compassion is emerging as one strategy that has a positive correlation with nurse well-being and a negative association with burnout, depression, and anxiety. In this article, we identify and translate strategies to promote self-compassion in perinatal nurses.

Resilience and Ethics in Nursing Education and Practice: Needs and Opportunities.

BACKGROUND: Nursing faculty and clinicians are leaving the profession due to increased workload and burnout. Evidence-based interventions to build skills in resilience and well-being are encouraged; however, strategies to implement them in nursing curricula and nurse residency programs (NRPs) are not well known. PURPOSE: To understand the current state of resilience, well-being, and ethics content in the curriculum in schools of nursing and NRPs in the state of Maryland as part of a statewide initiative for Renewal, Resilience and Retention of Maryland Nurses (R 3 ). METHODS: A descriptive survey was distributed to leaders of all Maryland nursing schools and NRP directors. RESULTS: Respondents (n = 67) reported minimal resilience, well-being, and ethics content. Teaching modalities included lecture, journaling, mindfulness, and the code of ethics. Barriers included lack of faculty knowledge, low priority, time constraints, and limited resources. CONCLUSION: Resilience, well-being, and ethics content is limited in nursing curricula. Developing educator skills and best practices to foster resilience and ethical practice are needed.

Progressive familial intrahepatic cholestasis-outcome and time to transplant after biliary diversion according to genetic subtypes.

Background: Progressive familial intrahepatic cholestasis (PFIC) is a heterogeneous disease characterized by progressive cholestasis in early childhood. Surgical therapy aims at preventing bile absorption either by external or internal biliary diversion (BD). Several different genetic subtypes encode for defects in bile transport proteins, and new subtypes are being discovered ongoingly. Overall, the literature is scarce, however, accumulating evidence points to PFIC 2 having a more aggressive course and to respond less favorable to BD. With this knowledge, we aimed to retrospectively analyze the long-term outcome of PFIC 2 compared to PFIC 1 following BD in children at our center. Methods: Clinical data and laboratory findings of all children with PFIC, who were treated and managed in our hospital between 1993 and 2022, were analyzed retrospectively. Results: Overall, we treated 40 children with PFIC 1 (n = 10), PFIC 2 (n = 20) and PFIC 3 (n = 10). Biliary diversion was performed in 13 children (PFIC 1, n = 6 and 2, n = 7). Following BD, bile acids (BA) (p = 0.0002), cholesterol (p < 0.0001) and triglyceride (p < 0.0001) levels significantly decreased only in children with PFIC 1 but not in PFIC 2. Three out of 6 children (50%) with PFIC 1 and 4 out of 7 children (57%) with PFIC 2 required liver transplantation despite undergoing BD. On an individual case basis, BA reduction following BD predicted this outcome. Of the 10 children who had PFIC 3, none had biliary diversion and 7 (70%) required liver transplantation. Conclusion: In our cohort, biliary diversion was effective in decreasing bile acids, cholesterol levels as well as triglycerides in the serum only in children with PFIC 1 but not PFIC 2. On an individual case level, a decrease in BA following BD predicted the need for liver transplantation.

The Mindful Ethical Practice and Resilience Academy: Sustainability of Impact.

BACKGROUND: Nurses face many ethical challenges, placing them at risk for moral distress and burnout and challenging their ability to provide safe, high-quality patient care. Little is known about the sustainability of interventions to address this problem. OBJECTIVE: To determine the long-term impact on acute care nurses of a 6-session experiential educational program called the Mindful Ethical Practice and Resilience Academy (MEPRA). METHODS: MEPRA includes facilitated discussion, role play, guided mindfulness and reflective practices, case studies, and high-fidelity simulation training to improve nurses' skills in mindfulness, resilience, and competence in confronting ethical challenges. A prospective, longitudinal study was conducted on the impact of the MEPRA curriculum at 2 hospitals in a large academic medical system. The study involved surveys of 245 nurses at baseline, immediately after the intervention, and 3 and 6 months after the intervention. RESULTS: The results of the intervention were generally sustained for months afterward. The most robust improvements were in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger. Some outcomes were not improved immediately after the intervention but were significantly improved at 3 months, including anxiety and empathy. Depersonalization and turnover intentions were initially reduced, but these improvements were not sustained at 6 months. CONCLUSIONS: Many MEPRA results were sustained at 3 and 6 months after conclusion of the initial foundational program. Some outcomes such as depersonalization and turnover intentions may benefit from boosters of the intervention or efforts to supplement the training by making organizational changes to the work environment.

Curricular Integration of Virtual Reality in Nursing Education.

AIM: The purpose of this article was to evaluate the ability of an interactive virtual reality (VR) platform guided by standards of best practice to provide an effective immersive learning environment. We specifically evaluated usability of the platform and learners' perceptions of the experience. BACKGROUND: A variety of strategies are needed to train a highly competent nursing workforce. METHODS: We conducted a quantitative cross-sectional study to evaluate the VR experience using the System Usability Scale (SUS)® and the Simulation Effectiveness Tool-Modified (SET-M). RESULTS: Post-simulation evaluations were completed by 127 prelicensure and 28 advanced practice students. On the SUS scale, students found the overall VR system easy to navigate, and on the SET-M, they rated the VR experience positively. CONCLUSION: Immersive technology such as VR with a defined curriculum and facilitated debriefing can be valuable for student learning and may ultimately effect patient care. [J Nurs Educ. 2023;62(6):364-373.].

Burnout and moral resilience in interdisciplinary healthcare professionals.

AIMS AND OBJECTIVES: To examine demographic and work characteristics of interdisciplinary healthcare professionals associated with higher burnout and to examine whether the four domains of moral resilience contribute to burnout over and above work and demographic variables. BACKGROUND: Healthcare professionals experience complex ethical challenges on a daily basis leading to burnout and moral distress. Measurement of moral resilience is a new and vital step in creating tailored interventions that will foster moral resilience at the bedside. DESIGN: Cross-sectional descriptive design. METHODS: Healthcare professionals in the eastern USA were recruited weekly via email for 3 weeks in this cross-sectional study. Online questionnaires were used to conduct the study. The STROBE checklist was used to report the results. RESULTS: Work and demographic factors, such as religious preference, years worked in a healthcare profession, practice location, race, patient age, profession and education level, have unique relationships with burnout subscales and turnover intention, with the four subscales of moral resilience demonstrating a protective relationship with outcomes above and beyond the variance explained by work and demographic characteristics. CONCLUSIONS: Higher moral resilience is related to lower burnout and turnover intentions, with multiple work demographic correlates allowing for potential areas of intervention to deal with an increase in morally distressing situations occurring at the bedside. Additionally, patterns of significant and non-significant relationships between the moral resilience subscales and burnout subscales indicate that these subscales represent unique constructs. RELEVANCE TO CLINICAL PRACTICE: Understanding the everyday, pre-pandemic correlations of moral resilience and burnout among interdisciplinary clinicians allows us to see changes that may exist. Measuring and understanding moral resilience in healthcare professionals is vital for creating ways to build healthier, more sustainable clinical work environments and enhanced patient care delivery.

Transcriptomic profiles of human livers undergoing rewarming machine perfusion before transplantation-first insights.

Machine perfusion by controlled oxygenated rewarming (COR) is feasible and safe in clinical application and result in a promising outcome. This study utilizes next-generation sequencing (NGS) to investigate the transcriptome of human liver tissue undergoing COR before liver transplantation. Cold-stored livers were subjected to machine-assisted slow COR for ~120 min before transplantation. Biopsies were taken before (preCOR) and after COR (postCOR) and 1 h after reperfusion (postRep). The samples were sequenced, using RNA-seq to analyze differential transcriptional changes between the different stages and treatments of the grafts. Comparison of differential gene expression preCOR and postCOR demonstrated 10 upregulated genes. postRep 97 and 178 genes were upregulated and 7 and 13 downregulated compared to preCOR and postCOR, respectively. A shift of gene expressions by machine perfusion to the TGF-beta pathway was observed. The present study demonstrates distinct transcriptome profiles associated with machine perfusion by COR and transplantation of human livers. Such data provide a deeper understanding of the molecular mechanisms of machine perfusion technology in human liver transplantation.

Mindful Ethical Practice and Resilience Academy: Equipping Nurses to Address Ethical Challenges.

BACKGROUND: Ethical challenges in clinical practice significantly affect frontline nurses, leading to moral distress, burnout, and job dissatisfaction, which can undermine safety, quality, and compassionate care. OBJECTIVES: To examine the impact of a longitudinal, experiential educational curriculum to enhance nurses' skills in mindfulness, resilience, confidence, and competence to confront ethical challenges in clinical practice. METHODS: A prospective repeated-measures study was conducted before and after a curricular intervention at 2 hospitals in a large academic medical system. Intervention participants (192) and comparison participants (223) completed study instruments to assess the objectives. RESULTS: Mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly after the intervention. Resilience and mindfulness were positively correlated with moral competence and work engagement. As resilience and mindfulness improved, turnover intentions and burnout (emotional exhaustion and depersonalization) decreased. After the intervention, nurses reported significantly improved symptoms of depression and anger. The intervention was effective for intensive care unit and non-intensive care unit nurses (exception: emotional exhaustion) and for nurses with different years of experience (exception: turnover intentions). CONCLUSIONS: Use of experiential discovery learning practices and high-fidelity simulation seems feasible and effective for enhancing nurses' skills in addressing moral adversity in clinical practice by cultivating the components of moral resilience, which contributes to a healthy work environment, improved retention, and enhanced patient care.

Measuring Health Care Interprofessionals' Moral Resilience: Validation of the Rushton Moral Resilience Scale.

Background: Health care interprofessionals face competing obligations to their patients, employers, and themselves. When ethical conflicts ensue and competing obligations cannot be resolved, health care interprofessionals have reported experiencing symptoms of burnout, moral distress, and other types of moral suffering. Recently, moral resilience or "the capacity of an individual to sustain or restore their integrity in response to moral adversity," has been proposed as a resource to address moral suffering while contributing to well-being. Objectives: Develop and validate an instrument to measure moral resilience. Design: Phase one: item development and expert review. Phase two: focus groups with health care interprofessionals to refine items. Phase three: psychometric testing. Setting/Subjects: Seven hundred twenty-three health care interprofessionals participated; inclusion criteria included being a chaplain, nurse, physician, or social worker, and having practiced at least 1 year. Participants were recruited from seven academic and community hospitals in the Eastern United States. Results: One hundred items were created for expert review. Following focus groups to refine items, 35 items remained for psychometric testing. Eighteen items were removed following item analysis. Exploratory factor analysis (EFA) of the remaining items suggested a four-factor solution, titled Responses to Moral Adversity, Personal Integrity, Moral Efficacy, and Relational Integrity, respectively. Overall reliability was α = 0.84. The Rushton Moral Resilience Scale (RMRS) demonstrated convergent validity with the Connor Davidson Resilience Scale-10 and criterion validity with the Maslach Burnout Inventory-Human Services Survey. Conclusion: The RMRS demonstrated acceptable validity and reliability. Examining the factor structure of moral resilience contributes to burgeoning moral resilience science and enables future research. Moral Resilience offers a promising pathway to support interprofessionals' integrity even when faced with ethical challenges.

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM.

Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

Infectivity and stability of hepatitis C virus in different perfusion solutions.

BACKGROUND: Owing to organ shortage, transplantation of organs from HCV (hepatitis C virus) viremic donors into HCV negative individuals is getting more and more accepted. However, transmission of HCV to the host is nearly universal. Until now it is unknown if preservation solutions (PS) might alter infectivity and stability of HCV in the transplant setting. Therefore, seven different preservation solutions (PS) with variable composition were tested in vitro for their direct anti- and proviral effects on HCV. METHODS: In vitro grown HCV based on the JFH-1 isolate was used to characterize the effect of seven different PS on the HCV replication cycle including HCV attachment, entry, replication, and assembly. In addition, HCV stability in PS was tested. RESULTS: Overall, 6/7 PS enhanced HCV infectivity: IGL-1 increased HCV attachment and entry, UW Belzer and Perfadex boosted HCV entry. Production of novel viral particles was enhanced in HTK, UW Belzer, and IGL-1. In contrast, viral replication was significantly reduced in HTK solution while all other PS had no effect on HCV RNA replication. HCV was significantly more stable in HTK solution. Euro Collins was the only PS that did not support HCV infectivity in cell culture. None of the used PS showed cytotoxic effects. CONCLUSION: Our data indicate that HCV infectivity and stability is maintained by several PS.

Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial.

Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.

Student preferences and perceptions of learning from vSIM for Nursing™.

This study explored BSN students' perceptions of learning with vSim for Nursing™. Using a mixed methods design with 99 students, key points of learning were medication administration and respiratory interventions. Qualitative data demonstrated learning of assessment, prioritization, and emergency management. The top student preferences of how to use virtual simulation were as a clinical makeup or to enhance lecture. The findings support the use of virtual simulation and provide data to guide nurse educators to more strategically integrate virtual simulation exercises.

Methylene Blue Treatment of Grafts During Cold Ischemia Time Reduces the Risk of Hepatitis C Virus Transmission.

Background: Although organ shortage is a rising problem, organs from hepatitis C virus (HCV) ribonucleic acid (RNA)-positive donors are not routinely transplanted in HCV-negative individuals. Because HCV only infects hepatocytes, other organs such as kidneys are merely contaminated with HCV via the blood. In this study, we established a protocol to reduce HCV virions during the cold ischemic time. Methods: Standard virological assays were used to investigate the effect of antivirals, including methylene blue (MB), in different preservation solutions. Kidneys from mini pigs were contaminated with Jc1 or HCV RNA-positive human serum. Afterwards, organs were flushed with MB. Hypothermic machine perfusion was used to optimize reduction of HCV. Results: Three different antivirals were investigated for their ability to inactivate HCV in vitro. Only MB completely inactivated HCV in the presence of all perfusion solutions. Hepatitis C virus-contaminated kidneys from mini pigs were treated with MB and hypothermic machine perfusion without any negative effect on the graft. Human liver-uPA-SCID mice did not establish HCV infection after inoculation with flow through from these kidneys. Conclusions: This proof-of-concept study is a first step to reduce transmission of infectious HCV particles in the transplant setting and might serve as a model for other relevant pathogens.

Decentralization: The Corridor Is the Problem, Not the Alcove.

There is controversy today about whether decentralized intensive care unit (ICU) designs featuring alcoves and multiple sites for charting are effective. There are issues relating to travel distance, visibility of patients, visibility of staff colleagues, and communications among caregivers, along with concerns about safety risk. When these designs became possible and popular, many ICU designs moved away from the high-visibility circular, semicircular, or box-like shapes and began to feature units with more linear shapes and footprints similar to acute bed units. Critical care nurses on the new, linear units have expressed concerns. This theory and opinion article relies upon field observations in unrelated research studies and consulting engagements, along with material from the relevant literature. It leads to a challenging hypothesis that criticism of decentralized charting alcoves may be misplaced, and that the associated problem may stem from corridor design and unit size in contemporary ICU design. The authors conclude that reliable data from research investigations are needed to confirm the anecdotal reports of nurses. If problems are present in current facilities, organizations may wish to consider video monitoring, expanded responsibilities in the current buddy system, and use of greater information sharing during daily team huddles. New designs need to involve nurses and carefully consider these issues.

Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice.

Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.