Using "think aloud" to capture clinical reasoning during patient simulation.

Think Aloud (TA), a strategy in which subjects are instructed to verbalize thoughts as they occur while completing an assigned task, was integrated into a study of clinical reasoning during high fidelity patient simulation by baccalaureate nursing students. TA methods in nursing education research with patient simulation have not previously been reported. Concurrent TA (verbalization of thoughts in short-term memory) and retrospective TA (reflective thoughts verbalized during an immediate post-simulation interview) methods facilitated the collection of rich and meaningful data. Students demonstrated distinct patterns in verbalization during concurrent TA, including public and private thoughts, narration of care, and the use of the pause to facilitate clinical reasoning. Retrospective TA data provided rich descriptions of reflection-on-action. TA provides a rich source of data regarding clinical reasoning as experienced by the baccalaureate nursing student during high fidelity patient simulation.

A Discount Approach to Reducing Nursing Alert Burden.

BACKGROUND: Numerous programs have arisen to address interruptive clinical decision support (CDS) with the goals of reducing alert burden and alert fatigue. These programs often have standing committees with broad stakeholder representation, significant governance efforts, and substantial analyst hours to achieve reductions in alert burden which can be difficult for hospital systems to replicate. OBJECTIVE: This study aimed to reduce nursing alert burden with a primary nurse informaticist and small support team through a quality-improvement approach focusing on high-volume alerts. METHODS: Target alerts were identified from the period of January 2022 to April 2022 and four of the highest firing alerts were chosen initially, which accounted for 43% of all interruptive nursing alerts and an estimated 86 hours per month of time across all nurses occupied resolving these alerts per month. Work was done concurrently for each alert with design changes based on the Five Rights of CDS and following a quality-improvement framework. Priority for work was based on operational engagement for design review and approval. Once initial design changes were approved, alerts were taken for in situ usability testing and additional changes were made as needed. Final designs were presented to stakeholders for approval prior to implementation. RESULTS: The total number of interruptive nursing alert firings decreased by 58% from preintervention period (1 January 2022-30 June 2022) to postintervention period (July 1, 2022-December 31, 2022). Action taken on alerts increased from 8.1 to 17.3%. The estimated time spent resolving interruptive alerts summed across all nurses in the system decreased from 197 hours/month to 114 hours/month. CONCLUSION: While CDS may improve use of evidence-based practices, implementation without a clear framework for evaluation and monitoring often results in alert burden and fatigue without clear benefits. An alert burden reduction effort spearheaded by a single empowered nurse informaticist efficiently reduced nursing alert burden substantially.

Efficient Workflow Analysis to Address Paper Persistence in Tuberculin Testing.

Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Implementation of Clinical Decision Support to Identify and Improve Treatment for Severe PIVIE.

Pediatric patients are at high risk of peripheral intravenous infiltration or extravasation (PIVIE) leading to injury and increased costs. Most of the work in addressing PIVIE has focused on the implementation of workflow bundles and evidenced based guidelines. This project showed that Clinical Decision Support can be used to help support identification and treatment of Severe PIVIE through use of an interruptive alert that increases placement of vascular access team consults.

Realizing the Full Potential of Clinical Decision Support: Translating Usability Testing into Routine Practice in healthcare operations.

BACKGROUND: Clinical Decision Support (CDS) tools have a mixed record of effectiveness, often due to inadequate alignment with clinical workflows and poor usability. While there's a consensus that usability testing methods address these issues, in practice, usability testing is generally only used for selected projects (such as funded research studies). There is a critical need for CDS operations to apply usability testing to all CDS implementations. OBJECTIVES: In this State of the Art / Best Practice paper, we share challenges with scaling usability in healthcare operations and alternative methods and CDS governance structures to enable usability testing as a routine practice. METHODS: We coalesce our experience and results of applying guerilla in-situ usability testing to over 20 projects in 1 year period with the proposed solution. RESULTS: We demonstrate the feasibility of adopting "guerilla in-situ usability testing" in operations and their effectiveness in incorporating user feedback and improving design. CONCLUSION: Although some methodological rigor was relaxed to accommodate operational speed, the benefits outweighed the limitations. Broader adoption of usability testing may transform CDS implementation and improve health outcomes.

Avoiding Unintended Consequences of Pediatric Blood Order Set Updates through In Situ Usability Testing.

BACKGROUND: Blood product ordering is a complex process and mistakes can harm patients and lead to poor outcomes. Orders and order sets can be designed to help mitigate errors, but major changes in design can unintentionally cause new errors. OBJECTIVES: Our objective was as follows: (1) utilize formative in situ usability testing to iteratively improve the design of a redesigned blood product order set prior to go-live, (2) implement changes based on feedback derived from this testing, and (3) compare the error rate, system usability scale (SUS) score, time to task completion, and click counts between the prior order set in use at the time and the revised redesigned order set. METHODS: A multidisciplinary project team convened to redesign blood product orders and order sets from scratch based on a review of the literature and benchmarking against four pediatric academic institutions with the goal of addressing prior ordering errors. The newly redesigned blood product order set was iteratively updated via in situ formative usability testing performed with available clinical users using a concurrent think-aloud protocol in real clinical environments. Errors, SUS scores, time to task completion, and click counts were assessed for the revised redesigned order set using summative testing. RESULTS: Formative usability testing with 20 participants led to seven design changes in the redesigned order set which reduced the error rate at go-live. Summative usability testing showed that even though the usability scores were only slightly improved for the revised redesigned order set, the error rates in blood orders were significantly decreased. CONCLUSION: Usability testing can identify design errors early in the process which can be rectified prior to implementation, thus avoiding unintended consequences of changes.

HIV vaccines induce CD8+ T cells with low antigen receptor sensitivity.

Current HIV vaccines designed to stimulate CD8+ T cells have failed to induce immunologic control upon infection. The functions of vaccine-induced HIV-specific CD8+ T cells were investigated here in detail. Cytotoxic capacity was significantly lower than in HIV controllers and was not a consequence of low frequency or unaccumulated functional cytotoxic proteins. Low cytotoxic capacity was attributable to impaired degranulation in response to the low antigen levels present on HIV-infected targets. The vaccine-induced T cell receptor (TCR) repertoire was polyclonal and transduction of these TCRs conferred the same reduced functions. These results define a mechanism accounting for poor antiviral activity induced by these vaccines and suggest that an effective CD8+ T cell response may require a vaccination strategy that drives further TCR clonal selection.

A transgenic wnt8a:PAC reporter reveals biphasic regulation of vertebrate mesoderm development.

Vertebrate wnt8a links anteroposterior and dorsoventral axis patterning, but the regulation of wnt8a expression and its relationship to mesoderm induction and maintenance pathways is unclear. To address this, we have generated zebrafish transgenic for a modified genomic PAC clone that expresses EGFP from the wnt8a locus. The EGFP reporter transgene is expressed in a pattern nearly identical to wnt8a, including maternal deposition, expression in the ventrolateral mesoderm and in the yolk syncytial layer. Loss of function studies show that wnt8a expression is under biphasic control by Nodal and No Tail/Brachyury, whereby early phase expression is Nodal-dependent but late phase expression is Ntl/Bra dependent. EGFP fluorescence persists in cells that transcribe the reporter, thus comprising a tracer for ventrolaterally derived mesodermal lineages. We use this property to show that wnt8a expression marks Nodal-independent tail mesoderm formation and that Ntl/Bra predominantly regulates wnt8a in paraxial mesoderm progenitors.

End-of-life care in nursing homes: the high cost of staff turnover.

Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.

Symptom occurrence and associated clinical factors in nursing home residents with cancer.

Little is known about the factors that contribute to symptoms in nursing home residents with cancer. We compared rates of symptoms in residents with (n = 1,022) and without cancer (n = 9,910) and examined physiologic, psychologic and situational factors potentially related to symptoms in residents with cancer. Pain, shortness of breath, vomiting, weight loss, and diarrhea were significantly (p < .05) more prevalent in residents with cancer. Cancer treatments, comorbid illnesses, and situational factors were not consistently correlated with symptoms. Improved symptom control was especially needed for the 30% of residents with cancer who clinically deteriorated within 3 months of admission; physical dependence and deteriorating clinical status were associated with pain, shortness of breath, and weight loss.

Embracing quality and safety education for the 21st century: building interprofessional education.

The education of health professions students is rooted historically in time-honored and silo-bound traditions of pedagogy and content not easily influenced by outside forces. However, the quality chasm work of the Institute of Medicine, Institute of Healthcare Improvement, Quality and Safety Education for Nurses, and other groups has led to a remarkable willingness to change at one academic health sciences university. This article describes one university's strategies, challenges, and successes in delivering interprofessional educational programs. Four interprofessional learning activities, developed using a plan-do-study-act model and focused on teamwork, quality, and safety, are presented. Challenges and successes encountered are described as well as a curricular framework to enhance sustainability.

CNAs' experiences in the nursing home: "It's in my soul".

Issues affecting CNAs' ability to do the job can affect resident care quality. The purpose of this study was to explore the meaning of CNAs' experiences in the nursing home. A naturalistic design using qualitative methods guided data collection and analysis. Data were analyzed using qualitative content analysis. Four themes emerged: Transitioning Between Two Worlds, Responding to the Call, Living the Job, and Transcending the Job. The challenge is to create strategies that identify CNAs'passion for the job, support their ability to balance daily tasks with relationships, and value their knowledge and contributions to the care team.

Nursing leadership in academic nursing: The wisdom of development and the development of wisdom.

The purpose of this article is to discuss insights derived from adult cognitive developmental theories and relate the insights to vertical leadership development in academic nursing contexts. Equipped with developmental understanding, academic leaders are in a better position to support the vertical leadership development of one's self, faculty, peers, and colleagues. From a cognitive developmental perspective, the authors' reason as leaders develop, grow, and evolve, sense making becomes more sophisticated and nuanced resulting in the development of wisdom. Leadership wisdom is a function of horizontal (acquisition of information, skills, and competencies) and vertical development (the development of more complex and sophisticated ways of thinking). Ways to enhance vertical development, and sense making to cultivate wisdom are discussed. Principles and practices that promote vertical development in self and others deepens performance expectations of those in the academy and supports personal professional development and organizational success.

Student-Perceived Influences on Performance During Simulation.

BACKGROUND: Understanding the effect of the context of simulation to learning and performance is critical to ensure not only optimal learning but to provide a valid and reliable means to evaluate performance. The purpose of this study is to identify influences on performance from the student perspective and understand the contextual barriers inherent in simulation before using simulation for high-stakes testing. METHOD: This study used a qualitative descriptive design. Senior nursing students (N = 29) provided nursing care during simulation. Vocalized thoughts during simulation and reflective debriefing were digitally recorded and transcribed verbatim. Thematic analysis was conducted on transcribed data. RESULTS: Student performance during simulation was influenced by anxiety, uncertainty, technological limitations, and experience with the patient condition. Students had few previous simulation-based learning experiences that may have influenced performance. CONCLUSIONS: More needs to be understood regarding factors affecting simulation performance before pass-or-fail decisions are made using this technology. [J Nurs Educ. 2016;55(7):396-398.].

End-of-Life Care in Nursing Homes with Greater versus Less Palliative Care Knowledge and Practice.

BACKGROUND: Many older adults in nursing homes (NHs) lack palliative care (PC) access; but little is known about whether access to PC knowledge and practice (beyond hospice) impacts residents' care. OBJECTIVE: The study objective was to evaluate how differing levels of NH PC knowledge and practice are associated with residents' end-of-life health care use. METHODS: In 2009/10 we surveyed a stratified random sample of U.S. NHs and asked directors of nursing (DONs) PC knowledge and practice questions from Thompson and colleagues' validated PC Survey. This study includes 1981 NHs with complete survey responses and the 58,876 residents who died in these facilities between July 2009 and June 2010. Medicare resident assessment (minimum data set [MDS]) and claims data from July 2009 through June 2010 were used to determine outcomes and a NH's hospice use. Multivariate logistic regressions examined whether residing in NHs with higher PC scores was associated with documented six-month prognoses and receipt of aggressive treatments, including hospital and emergency room (ER) use in the last 30 days of life. RESULTS: Controlling for NH hospice use, being in a NH with higher PC care knowledge scores was associated with residents having a higher likelihood of documented six-month prognoses and lower likelihoods of having feeding tubes, injections, restraints, suctioning, and end-of-life hospital and ER use. Being in a NH with higher PC practice scores was associated with a lower likelihood of having feeding tubes and ER visits. CONCLUSION: Policies and advocacy promoting the development of NH PC knowledge and practices could potentially improve care and reduce hospital and ER use.

Cue recognition by undergraduate nursing students: an integrative review.

Patients express multiple cues, ranging from subtle to overt. Clinical cues may signal changes or the presence of stability in the patient's condition. Little is known about the number and types of cues recognized by beginning nurses. This article reports the results of an integrative review of the literature published between 1964 and 2013 concerning recognition of clinical cues by undergraduate nursing students. Search terms included cue, cue recognition, clinical cue, and clinical reasoning. Twenty-seven studies met inclusion criteria. Initial evidence exists of differences in cue recognition between novice and expert nurses. Influences on cue recognition include familiarity with the patient or the patient's health condition. Cue recognition does not necessarily predict presence or quality of nursing actions. International research concerning cue recognition by nurses is in its infancy. Opportunities exist to further the science through use of rigorous design and multisite sampling.

Sampling challenges in nursing home research.

BACKGROUND: Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging. OBJECTIVES: To compare characteristics of nursing homes that dropped from the study to those that completed the study. METHODS: One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview. RESULTS: Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team. CONCLUSION: Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

Quality of care and quality of dying in nursing homes: two measurement models.

BACKGROUND: There is consistent evidence of significant variation in the quality of end-of-life care among nursing homes, with many facilities ill-prepared to provide optimal physical and psychological care that is culturally sensitive and respectful of the needs and preferences of residents and their family members. There is continued evidence that what is impeding efforts to improve care is that most measurement tools are hampered by a lack of distinction between quality of care and quality of dying as well as a lack of complete psychometric evaluation. Further, health services researchers cite the need to include "system-level" factors, variables that reflect leadership, culture, or informal practices, all of which influence end-of-life care and can be used to differentiate one setting from another. The purpose of this article is to report advancement in conceptualizing quality end-of-life care in nursing homes and to offer a refined approach to measurement. METHODS: Two latent constructs are tested: quality of care (composed of system-level factors) and quality of dying (comprised of resident/family outcomes). Data obtained from 85 Midwestern nursing homes and 1282 interviews with bereaved family members were used to evaluate both constructs. RESULTS: Confirmatory factor analyses were conducted and evidence of validity and reliability were obtained for both. CONCLUSION: For health services researchers, expanded models that include system-level factors as well as more comprehensive and psychometrically sound models of resident outcomes stand to inform efforts to improve care in this very important area.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes.

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.