Teaming Up for Community Health Simulation Intervention: A Quasi-Experimental Study.

AIM: The aim of this study was to examine whether participating in a team-based simulation intervention would improve nursing students' empathy and commitment to addressing social determinants of health (SDOH) and interprofessional teamwork attitudes, beliefs, and behaviors. Outcomes were compared for intraprofessional versus interprofessional team participation. BACKGROUND: Nursing students must learn strategies to address SDOH, but this content is not well integrated in curricula. Teaming Up for Community Health was created to provide SDOH experiential team learning. METHOD: Eighty-five nursing students participated in the intraprofessional comparison group or interprofessional intervention group. Surveys were completed before and after the intervention and two months later. RESULTS: Participants had heightened empathy and commitment to addressing SDOH at baseline. Interprofessional teamwork beliefs and behaviors improved for both groups. CONCLUSION: Experiential learning about SDOH should focus on improving students' self-confidence and performance. Based on the study results, experiential team learning should be threaded through curricula.

Family support person role during resuscitation: A qualitative exploration.

AIMS AND OBJECTIVES: To provide guidance to nurses by examining how critical care nurses perceive and perform the family support person role during resuscitation. BACKGROUND: Nurses can serve as family support person when families witness a loved one's resuscitation. However, few studies have examined the role of family support person to provide nurses with sufficient knowledge to enact the role. DESIGN: An exploratory-descriptive qualitative design with individual, semi-structured interviews. METHODS: Sixteen critical care nurses who had served as family support person completed interviews. The data were analysed by thematic analysis. COREQ guidelines were followed. RESULTS: Six themes were identified: Hard but Rewarding Role, Be With, Assess, First Moments, Explain and Support. Findings explicated nurses' perceptions of the role and key role activities. CONCLUSIONS: Nurses perceived the role as hard but rewarding. Role challenges included the need for quick, accurate assessments and interventions to keep family members safe, informed and supported, while allowing them to witness resuscitation. Key role activities included: being fully present and compassionately attentive to family, continuously assessing family members, coordinating the first moments when family presence during resuscitation commences, explaining in simple, tailored terms the resuscitation activities, and supporting the family emotionally and psychologically through a variety of strategies. Nurses noted the high variability in how families respond and the complexity of simultaneously performing the multi-faceted role activities. RELEVANCE TO CLINICAL PRACTICE: To effectively support the growing global trend of family presence during resuscitation, nurses need the knowledge this study provides about how to fulfil the family support person role. Identifying the role activities may facilitate development of clinical guidelines and educational preparation for the role. Nurses can refine the many skills this role requires, building their competence and confidence, to increase opportunities for family members to experience family presence during resuscitation in a safe, and high-quality manner.

The COVid-19 pandemic through the eyes of pediatric nurses: A qualitative study.

PURPOSE: This study explored pediatric nurses' lived experiences during the first calendar year (2020) of the COVid-19 pandemic. DESIGN AND METHODS: An electronic survey used an exploratory-descriptive qualitative approach to gather data from 231 pediatric nurses working in a variety of settings across the United States. The survey consisted of seven open-ended questions to capture participants' experiences in the workplace. Thematic analysis was conducted to identify themes and associated subthemes. RESULTS: Seven themes emerged: Unique Aspects of COVid-19 in the Pediatric Population; Visitor Restrictions and Isolation Increased Stress; Navigating Changing Knowledge and Misinformation; Personal Protective Equipment Challenges; Living in Fear; Pride in the Profession; and Profession at Risk. CONCLUSIONS: Pediatric nurses working in the initial year of the COVid-19 pandemic faced numerous challenges consistent with those shared by the profession at large in addition to some unique to their patient population. Of greatest concern is the dismay many participants conveyed in their perception of administrative and public support and in their flagging commitment to the profession. PRACTICE IMPLICATIONS: This study highlights the need for nurse self-care, cultural reform in healthcare settings to engage front line providers in decision making, and proactive strategies to recruit and retain professional nurses.

Nurses' experiences of ethical and legal issues in post-resuscitation care: A qualitative content analysis.

BACKGROUND: Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care. OBJECTIVE: To explore nurses' experiences of ethical and legal issues in post-resuscitation care. RESEARCH DESIGN: This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis. PARTICIPANTS AND RESEARCH CONTEXT: In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were analyzed by conventional content analysis. ETHICAL CONSIDERATIONS: The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected. FINDINGS: Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care. CONCLUSION: There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges.

Nurses' Perceptions Towards Resuscitated Patients: A Qualitative Study.

Nurses' perceptions of resuscitated patients may affect their care, and this has not been investigated in previous literature. The aim of this study was to explore nurses' perceptions towards resuscitated patients. In this descriptive-qualitative study seventeen clinical nurses participated using purposive sampling. In-depth, semi-structured interviews were conducted and data were analyzed by conventional content analysis. Four main categories emerged: Injured, undervalued, problematic, and destroyer of resources. Participants considered resuscitated patients to have multiple physical injuries, which are an important source of legal problems and workplace violence, and they believed that these patients will eventually die. Resuscitated patients are considered forgotten and educational cases. Iranian nurses have a strong negative perception towards resuscitated patients. Improving the quality of cardiopulmonary resuscitation, improving the knowledge and skills of personnel in performing resuscitation, and supporting managers and doctors to nurses in the post-resuscitation period can change the attitude of nurses and improve post-resuscitation care.

Improving Self-Efficacy of Patients With a New Ostomy With Written Education Materials: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement project was to determine if supplementing the current education process for new ostomates with standardized, health literate written education materials which are initiated preoperatively improves patient self-efficacy for management of their new ostomy. DESIGN: A convenience sample of 25 patients undergoing new ostomy placement were selected to receive the written education materials. The project occurred in two outpatient clinics and an 874-bed hospital. METHODS: Preoperative education by wound, ostomy, continence (WOC) nurses in the outpatient clinic was supplemented by the new health literate written education materials, and this education continued during the postoperative period before hospital discharge. Stoma self-efficacy was measured at three timepoints: pre- and posteducation in the outpatient clinic and before discharge from the hospital following surgery. FINDINGS: Mean total self-efficacy scores significantly increased from 27.32 (SD = 12.15, confidence intereval [CI] = 22.30, 32.34) pre-education in the clinic to 39.56 (SD = 9.26, CI = 35.74, 43.38) posteducation in the clinic (P = .000), and further increased to 47.20 (SD = 7.38, CI = 44.14, 50.25) at discharge from the hospital postsurgery (P = .0004). CONCLUSIONS: Initiating education preoperatively and supplementing it with standardized, health literate written education materials improved patients' stoma self-efficacy. By improving self-efficacy, patients may be more effective in self-management of their ostomy and better prepared to care for themselves upon discharge from the hospital to prevent complications and improve outcomes.

Simulations using telehealth to collaborate with other health-care professionals: effect on pre-licensure nursing students' competencies and amount of collaboration in the clinical setting.

Nursing students must gain experience collaborating with other members of the health-care team. Simulation can provide intra- and interprofessional collaboration experience; however, there can be barriers such as scheduling difficulties. We evaluated multi-patient, standardized patient simulations using telehealth as a strategy to provide baccalaureate nursing students with opportunities to learn and practice intra- and interprofessional collaboration. Forty-four final-semester nursing students participated. Student groups rotated to the simulation laboratory over 12 weeks to participate in two simulations that used telehealth to enable them to communicate patient concerns to other clinicians: a nurse practitioner, respiratory therapists, and social workers. Self-reported collaborative competencies and amount of collaboration in the clinical setting were measured at the start and end of the semester. Satisfaction and self-confidence were measured immediately after each simulation. For collaborative competencies, there was a statistically significant improvement in all item, subscale, and overall scale mean scores. Amount of clinical collaboration significantly improved, with the amount who indicated they never reported a patient concern to another professional decreasing from 39.5% to 6.8%. Findings also revealed a high level of student satisfaction and self-confidence following the simulations. Using telehealth to collaborate during simulations is a promising strategy to prepare nursing students for practice by improving collaborative competencies and encouraging more collaboration in the clinical setting.

Clinical Skills Performed By Iranian Emergency Nurses: Perceived Competency Levels and Attitudes Toward Expanding Professional Roles.

INTRODUCTION: Emergency nurses play an important role in the care of critically ill and injured patients, and their competency to perform clinical skills is vital to safe and effective patient care. The aim of this study was to evaluate the frequency of clinical skills performed and perceived competency levels among Iranian emergency nurses. In addition, attitudes toward expanding the professional roles of Iranian emergency nurses were also assessed. METHODS: In this descriptive correlational study, 319 emergency nurses from 30 hospitals in northwest Iran participated. Data were collected using a self-report questionnaire. Descriptive statistics and Pearson's correlation coefficient were used to present the findings. RESULTS: Overall competency of the emergency nurses was 73.31 ± 14.2, indicating a good level of perceived competence. The clinical skills most frequently performed were in the domains of organizational and workload competencies (3.43 ± 0.76), diagnostic function (3.25 ± 0.82), and the helping role (3.17 ± 0.83). A higher level of perceived competence was found for skills within these domains. Less frequently, participants performed skills within the domains of effective management of rapidly changing situations (2.70 ± 0.94) and administering and monitoring therapeutic interventions (2.60 ± 0.97); a lower perceived level of competence was noted for these clinical skills. There was a significant correlation between frequency of performing clinical skills and perceived competency level (r = 0.651, P < .001). Participants had positive attitudes toward expanding their professional roles (2.13 ± 0.92), with 81.5% agreeing it would improve their job satisfaction. DISCUSSION: Higher perceived competency levels were significantly associated with more frequent performance of clinical skills. This has implications for nurse managers and educators who may consider offering more frequent experiential and educational opportunities to emergency nurses. Expansion of nurses' roles could also result in increased experience in clinical skills and higher levels of competency. Research is needed to investigate nurses' clinical competence using direct and observed measures.

The utility of the surgical safety checklist for wound patients.

The purpose of this study was to determine the frequency of changes in patient care resulting from the use of a surgical safety checklist. Data were retrospectively obtained from 233 patients. The number and types of changes made to the patients' intra-operative management, based on the use of the checklist, were recorded. The number of patients whose management was modified as a result of the checklist was 113 (48%) out of 233. The total number of changes made was 132, and 18 patients had more than one modification made to their care plan. Further stratification was identified: among the 132 changes made, antibiotics were held or administered in 73 (55%), changes related to anaemia involving type and screen or transfusion occurred in 27 (20%), modifications made regarding anti-coagulation occurred in 8 (7%), beta-blockers were held in 2 (2%), an allergy was identified in 7 (5%), modifications made to the surgical procedure were 3 (2%) and a category labelled 'other' encompassed 9 (7%) changes. The surgical safety checklist is a standardised form of team communication that leads to modifications of the patient care plan in a large percentage of cases. The ever-increasing complexity of medicine means that patients are at greater risk of oversight and harm without the use of a checklist.

Gaining experience in the provider role: Exploration of a novel simulation intervention to prepare nurse practitioner students to detect and manage skin cancer.

BACKGROUND: The high prevalence and negative outcomes associated with skin cancer demand effective strategies to prepare nurse practitioner students to detect cancerous lesions and manage patient care. However, few studies have examined dermatologic simulations to prepare nurse practitioner students to detect and manage skin cancer. PURPOSE: An exploratory-descriptive qualitative approach was used to examine nurse practitioner students' experiences with simulations involving standardized patients wearing three-dimensional (3-D) prosthetic skin lesions, perceptions of ability to apply the simulations to clinical practice, and preferences for learning dermatologic care. METHODOLOGY: A convenience sample of 39 nurse practitioner students participated in simulations with standardized patients wearing 3-D skin lesions. Focus groups were conducted following simulation participation, and thematic analysis was performed by two researchers. RESULTS: Four themes emerged: Simulation provides a safe place to practice , Dermatology should be an integral part of education , Realism makes a difference , and Improved confidence and preparation for practice . CONCLUSIONS: Simulations with standardized patients wearing 3-D skin lesion prosthetics provided students the opportunity to assess, diagnose, and manage the care of patients with cancerous skin lesions. Participants valued the realistic practice with dermatologic care and reported improved confidence and preparation for practice. IMPLICATIONS: Faculty can use simulations to provide experiential learning about the provider role in general and as it pertains to skin cancer care. Attention to realism is important to aid in building students' confidence and preparation for practice.

Innovative Strategies to Facilitate Newly Licensed Nurse Transition to Practice During the COVID-19 Pandemic: A Quality Improvement Project.

As healthcare facilities transition from initial phases of the COVID-19 pandemic, it is imperative to consider innovative strategies to overcome instructional challenges presented to nursing schools in order to maintain a competent workforce amidst nursing shortages and increasing patient volumes and complexity. Nursing professional development practitioners will play a pivotal role in revitalizing transition-to-practice programs to meet the demands of the new workforce. This article details an academia-practice initiative for newly licensed nurses who enter practice during the pandemic.

Parental supporter during pediatric resuscitation: Qualitative exploration of caregivers' and healthcare professionals' experiences and perceptions.

BACKGROUND: Child resuscitation is a critical and stressful time for family caregivers and healthcare professionals. The aim of this study was to explore caregivers' and healthcare professionals' experiences and perceptions of a parental supporter during pediatric cardiopulmonary resuscitation to provide guidance to healthcare professionals on supporting parents and other family caregivers during resuscitation. METHODS: This study used an exploratory descriptive qualitative approach. The setting was two large referral pediatric governmental hospitals. Participants were 17 caregivers who had experienced their child's resuscitation, and 13 healthcare professionals who served on resuscitation teams in emergency rooms or intensive care wards. Semi-structured, in-depth interviews were conducted and data were analyzed using thematic analysis. COREQ guidelines were followed. RESULTS: Participants shared their experiences and perceptions of a parental supporter during pediatric resuscitation in three themes: 1) Requirement for the presence of a parental supporter, 2) Expectations of the parental supporter, and 3) Characteristics of the parental supporter. CONCLUSIONS: Study findings highlight the need for a parental supporter during pediatric resuscitation; however, there is no defined parental supporter role in current guiding policies due to limited research on this role. More research on the parental supporter role is needed so effective policies and protocols can be developed to enhance family-centered care practices in pediatric emergency and acute care settings.

Improving Reporting Culture Through Daily Safety Huddles.

BACKGROUND AND OBJECTIVES: A major obstacle to safer care is lack of error reporting, preventing the opportunity to learn from those events. On an acute care unit in a children's hospital in southeastern United States, error reporting and Survey for Patient Safety Culture (SOPS 1.0) scores fell short of agency benchmarks. The purpose of this quality improvement project was to implement a Safety Huddle Intervention to improve error reporting and SOPS 1.0 scores related to reporting. METHODS: Marshall Ganz's Change through Public Narrative Framework guided creation of the project's intervention: A story of self, a story of us, a story of now. A scripted Safety Huddle was conducted on the project unit daily for 6 weeks, and nurses on the project unit and a comparison unit completed the SOPS 1.0 before and after the intervention. Monthly error reporting was tracked on those same units. RESULTS: Error reporting by nurses significantly increased during and after the intervention on the project unit ( P = .012) but not on the comparison unit. SOPS 1.0 items purported to measure reporting culture showed no significant differences after the intervention or between project and comparison units. Only 1 composite score increased after the intervention: communication openness improved on the project unit but not on the comparison unit. CONCLUSION: Using a Safety Huddle Intervention to promote conversation about error events has potential to increase reporting of errors and foster a sense of communication openness. Both achievements have the capacity to improve patient safety.

Nursing core competencies for postresuscitation care in Iran: a qualitative study.

OBJECTIVE: This study explored nurses' perceptions of the core competencies required for providing postresuscitation care in both in-hospital and out-of-hospital cardiac arrest. DESIGN: Qualitative conventional content analysis. PARTICIPANTS: 17 nurses selected with purposeful sampling method. SETTING: Three educational hospitals in northwest of Iran. DATA COLLECTION AND ANALYSIS: Semi-structured interviews were used for data collection and they were analysed using conventional content analysis. RESULTS: Seven main categories have emerged from the data. The core competencies for nurses providing postresuscitation were identified as: quality assurance, providing evidence-based care, monitoring and presence, situation management, professionalism, positive attitude and providing family centred care. CONCLUSIONS: The postresuscitation period is a unique and critical time requiring highly competent nursing care. Several core competencies for providing high-quality nursing care during postresuscitation period were identified through nurses' experience in caring for patients postresuscitation.

Resuscitation Team Members' Perceptions of Supporting Parents During Cardiopulmonary Resuscitation of Children: A Systematic Review.

INTRODUCTION: Supporting parents is a crucial part of family-centered care in pediatric and neonate resuscitation. OBJECTIVES: The aim of this systematic review was to appraise and synthesize studies conducted to determine resuscitation team members' perspectives of support for parents during pediatric and neonate resuscitation. METHODS: The PRISMA model guided the systematic literature search of Google Scholar, PubMed, MEDLINE, CINAHL, Cochrane, and Scopus for studies published until May 2022. The authors independently screened all titles, abstracts, and full-text articles for eligibility. There was agreement about screened articles for inclusion. Full texts of all potentially relevant studies were evaluated for the rigor of the study design, sample, and analysis. This review included quantitative, qualitative, and mixed-methods studies. The quality of evidence across the included studies was assessed using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool as part of GRADE's (Recommendations Assessment, Development, and Evaluations) certainty rating process. RESULTS: There were 978 articles located. After reviewing for relevancy, 141 full-text articles were assessed, and 13 articles met criteria and were included in this review (4 quantitative, 7 qualitative, and 2 mixed-methods design). Five themes were revealed to summarize resuscitation team members' perspectives of parental support in pediatric resuscitation: providing information to parents, family facilitator, emotional support, presence of parents during resuscitation, and spiritual and religious support. CONCLUSIONS: The results of this systematic review can be used to improve support for parents by informing the education of resuscitation team members and clarifying policies and guidelines of resuscitation team roles to include support for parents.

Nurses' experiences of provision family-centred care in the postresuscitation period: A qualitative study.

AIM: This study aimed to explore nurses' experiences of providing family-centred care in the postresuscitation period. DESIGN: An exploratory-descriptive qualitative design was used. METHODS: In this qualitative study, in-depth, semi-structured interviews were conducted with 22 nurses in three educational hospitals. There were six participants who completed follow-up interviews to resolve questions generated during initial interviews. Data were analysed using conventional content analysis. RESULTS: Five main categories were extracted: continuous monitoring, facilitation of attendance, involvement in care, informing and emotional support. Despite the lack of organizational policies and guidelines, nurses explained how they work to provide family-centred care for families, especially those they assessed as having less possibility of aggressive behaviour and those with a better understanding of their loved one's condition. To provide postresuscitation family-centred care, nurses facilitated family attendance, involved them in some basic nursing care, and provided information and emotional support to the family members. CONCLUSION: Nurses attempted to follow the basic principles of family-centred care in the postresuscitation period. However, to improve the provision of care by nurses, it is necessary to embed family-centred care principles in institutional policies and guidelines and to conduct training for nurses. IMPLICATIONS FOR THE PROFESSION: Iranian nurses are interested in engaged families in the postresuscitation period. Correct implementations of such care that include all families need institutional policies and guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Exploring the Impact of Book Club Participation on Clinicians' Empathy and Reflection on Empathetic Practice: A Wake-Up Call.

INTRODUCTION:  Empathy is associated with desirable outcomes in healthcare, including improved patient-clinician rapport, fewer patient complications, and reduced clinician burnout. Despite these benefits, research suggests empathy declines during professional training. This study aimed to explore the impact of book club participation on clinicians' and trainees' empathy and perspectives on empathetic patient care. METHODS:  In this mixed-methods study, anesthesiology clinicians and trainees were invited to respond to a baseline online empathy survey followed by an invitation to read a book and to participate in one of four facilitated book club sessions. Post-intervention empathy was measured. The primary outcome of the quantitative analysis was a change in empathy scores as measured by the Toronto Empathy Questionnaire. A thematic analysis of book club sessions and open-ended comments in the post-intervention survey was conducted. RESULTS:  Participants included 74 responders to the baseline survey and 73 responders to the post-intervention survey. Empathy score change in the book club participants was not statistically significant from those who did not participate in any book club sessions (F(2, 39) = 0.42, p=0.66). Thematic analysis of the book club sessions revealed four themes that highlight how the book club enhanced empathy awareness among trainees and clinicians: 1) a wake-up call, 2) deciding whether to take action, 3) learning and nurturing empathy, and 4) changing the culture. CONCLUSION:  There were no significant changes in empathy scores associated with book club participation. Thematic analysis highlighted barriers toward empathetic patient care, areas for improvement, and voiced intentions to practice with heightened empathy. Book clubs may be a viable venue to nurture a culture of increased self-awareness and motivation to counteract loss of empathy, but just one experience may not be sufficient.

Advancing the Practice of Family Presence During Resuscitation: A Multifaceted Hospital-Wide Interprofessional Program.

BACKGROUND: After 3 decades of research, much is understood about the benefits of family presence during resuscitation (FPDR), yet translation into clinical practice has been lagging. This article provides guidance for nurse leaders seeking to advance FPDR by sharing the experience of establishing a multifaceted, hospital-wide program of education and policy development. OBJECTIVES: This quality improvement project aimed to (1) implement a hospital-wide FPDR program guided by policy, (2) evaluate classroom and simulation educational interventions, (3) examine chart review data for evidence of FPDR practice change, and (4) act on information learned to further improve the FPDR program and increase practice implementation. METHODS: The Plan-Do-Study-Act (PDSA) cycle provided the model for cyclic evaluation of the FPDR program at a rural Midwestern United States hospital. Interventions were classroom education for existing nursing staff, simulation for new nurses, and implementation of a hospital-wide policy. Outcome measures included nurses' perceptions of FPDR risks and benefits, self-confidence with FPDR, and evidence of practice change via retrospective chart review. RESULTS: Pilot data demonstrated a statistically significant improvement in nurses' perceptions of FPDR benefits and self-confidence post education, and the rate of FPDR practiced in the facility tripled. The PDSA cycle provided a useful paradigm for ongoing process improvement and program sustainability. DISCUSSION: After the delivery of an FPDR policy along with classroom and simulation education, an increase in the clinical implementation of FPDR occurred. The use of the PDSA cycle resulted in expanded approaches including the addition of FPDR to in situ mock codes.

Evidence-Based Critical Care Education for Oncology Nurses.

BACKGROUND: Advances in medical care for oncology patients have heightened the complexity of this patient population, leading to an increased need for lifesaving, critical care. Yet, there is a lack of literature on education to prepare nurses to provide care to critically ill oncology patients. OBJECTIVES: The purpose of this quality improvement project was to evaluate oncology nurses' mastery of basic and oncology-specific critical care knowledge after an evidence-based supplemental training intervention. METHODS: An 8-hour supplemental training intervention was developed to increase oncology nurses' knowledge about basic and oncology critical care by addressing score deficiencies noted on the Basic Knowledge Assessment Tool (9r version). Seventeen oncology nurses completed the supplemental training intervention. The Basic Knowledge Assessment Tool and an Oncology Knowledge Survey were administered pre and post supplemental training, and significant changes were detected with Wilcoxon signed rank tests. RESULTS: Mean total Basic Knowledge Assessment Tool scores significantly improved from 65.7 before initial course to 73.7 post supplemental training (P = .002). Oncology Knowledge Survey total scores increased from 75.3% to 80.9%, which was a statistically significant improvement (P = .039). CONCLUSIONS: Critical care training is imperative for oncology nurses preparing to care for high-acuity oncology patients. Adequate knowledge of basic and oncology-specific critical care is important to prevent adverse events and improve outcomes for this complex patient population.