Healthcare team resilience during COVID-19: a qualitative study.

BACKGROUND: Resilience, in the field of Resilience Engineering, has been identified as the ability to maintain the safety and the performance of healthcare systems and is aligned with the resilience potentials of anticipation, monitoring, adaptation, and learning. In early 2020, the COVID-19 pandemic challenged the resilience of US healthcare systems due to the lack of equipment, supply interruptions, and a shortage of personnel. The purpose of this qualitative research was to describe resilience in the healthcare team during the COVID-19 pandemic with the healthcare team situated as a cognizant, singular source of knowledge and defined by its collective identity, purpose, competence, and actions, versus the resilience of an individual or an organization. METHODS: We developed a descriptive model which considered the healthcare team as a unified cognizant entity within a system designed for safe patient care. This model combined elements from the Patient Systems Engineering Initiative for Patient Safety (SEIPS) and the Advanced Team Decision Making (ADTM) models. Using a qualitative descriptive design and guided by our adapted model, we conducted individual interviews with healthcare team members across the United States. Data were analyzed using thematic analysis and extracted codes were organized within the adapted model framework. RESULTS: Five themes were identified from the interviews with acute care professionals across the US (N = 22): teamwork in a pressure cooker, consistent with working in a high stress environment; healthcare team cohesion, applying past lessons to present challenges, congruent with transferring past skills to current situations; knowledge gaps, and altruistic behaviors, aligned with sense of duty and personal responsibility to the team. Participants' described how their ability to adapt to their environment was negatively impacted by uncertainty, inconsistent communication of information, and emotions of anxiety, fear, frustration, and stress. Cohesion with co-workers, transferability of skills, and altruistic behavior enhanced healthcare team performance. CONCLUSION: Working within the extreme unprecedented circumstances of COVID-19 affected the ability of the healthcare team to anticipate and adapt to the rapidly changing environment. Both team cohesion and altruistic behavior promoted resilience. Our research contributes to a growing understanding of the importance of resilience in the healthcare team. And provides a bridge between individual and organizational resilience.

A better way: training for direct observations in healthcare.

Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies.

A Novel Approach for Engagement in Team Training in High-Technology Surgery: The Robotic-Assisted Surgery Olympics.

INTRODUCTION: There is ongoing interest in the development of technical and nontechnical skills in healthcare to improve safety and efficiency; however, barriers to developing and delivering related training programs make them difficult to implement. Unique approaches to training such as "serious games" may offer ways to motivate teams, reinforce skill acquisition, and promote teamwork. Given increased challenges to teamwork in robotic-assisted surgery (RAS), researchers aimed to develop the "RAS Olympics," a game-based educational competition to improve skills needed to successfully perform RAS. METHODS: This pilot study was conducted at an academic medical center in Southern California. Robotic-assisted surgery staff were invited to participate in the "RAS Olympics" to develop their skills and identify opportunities to improve processes. Impact of the activity was assessed using surveys and debriefs. RESULTS: Sixteen operating room team members participated and reacted favorably toward the RAS-Olympics (average score, 4.5/5). They enjoyed the activity, would recommend all staff participate, felt that it was relevant to their work, and believed that they practiced and learned new techniques that would improve their practice. Confidence in skills remained unchanged. Participants preferred the RAS Olympics to traditional training because it provided an interactive learning environment. CONCLUSIONS: The successful implementation of the RAS Olympics provided insight into new opportunities to engage surgical staff members while also training technical and nontechnical skills. Furthermore, this shared experience allowed surgical staff members to gain a greater appreciation for their teammates and an understanding of the current challenges and methods to improve teamwork and communication while promoting safety and efficiency in RAS.

Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury.

Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.

Systems-Level Factors Affecting Registered Nurses During Care of Women in Labor Experiencing Clinical Deterioration.

BACKGROUND: Maternal morbidity and mortality are at their highest recorded levels in the United States, with more than 50% of maternal deaths deemed preventable. Women in labor often experience gradual morbidity, but signs of worsening condition may not be noticed by clinicians. Nurses are well-positioned to notice these signs, but performance obstacles inhibit nurses' work. There is scant literature describing the obstetric work system. This study sought to identify the systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration. METHODS: A convergent parallel mixed methods design combining survey data from the adapted Performance Obstacles for ICU Nurses instrument and semistructured interviews with registered nurses, certified nurse midwives, and physicians was used. Data were collected on the labor and delivery floor of a tertiary care center in Boston from July 2021 through August 2021. Interviews were coded using Bradley's integrated deductive and inductive methods and the Systems Engineering Initiative for Patient Safety (SEIPS) categories. RESULTS: Data included 46 surveys and 16 interviews. Identified performance obstacles were in the categories of tasks, tools and technology, and physical environment. Emergent themes included swamped, feeling inadequate, and is this safe? CONCLUSION: Issues with task overload, tools, and technology inhibit nurses' abilities to respond appropriately to women in labor who experience clinical deterioration. Emergent themes imply a relationship between task overload and burnout. Health care administrators should improve staffing, decrease nurse task load, and include bedside nurses in the redesign of tools and technology to mitigate the harms of performance obstacles.

A systematic concept analysis of healthcare team resilience in times of pandemic disasters.

BACKGROUND: The concept of resilience has been used as a descriptor for individuals and organizations with the dominant themes of bouncing back and moving forward. AIMS: To examine the concept of resilience in providers and healthcare teams during pandemic disasters. RESEARCH DESIGN: Walker and Avant's eight-step concept analysis method. DATA SOURCE: CINAHL, EBSCO Host, PubMed, and SCOPUS were searched using the combined terms "resilience" or "resiliency" or "resilient" and "healthcare professionals," or "healthcare worker" or "healthcare team" or "physician" or "nurse" or "doctor" and "pandemic" or "disaster." METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist was used to review the literature and apply findings using the eight-step Walker and Avant method for concept analysis. RESULTS: Three clusters emerged as attributes of individual resilience that may be applied to healthcare teams in times of pandemic disasters: (1) resilience is a dynamic contextual process, (2) resilience stabilizes the team to maintain a routine level of function, and (3) resilience is a catalyst for the actualization of innate or acquired skills and ability within the healthcare team. CONCLUSION: This analysis suggests that resilience enhances the healthcare team's ability to maintain function during acute changes created by pandemic disasters. Resilience in healthcare teams during pandemics requires future research to explore the phenomenon.

Patient and Provider Preferences for Monitoring Surgical Wounds Using an mHealth App: A Formative Qualitative Analysis.

Background: Surgical site infections complicate approximately 10% of all inpatient operations and account for nearly 20% of surgical re-admissions. Post-operative hospitalizations have become shorter over time, yet limited resources exist for patients to use at their home to communicate surgical wound problems with their medical providers. This study evaluated the attitudes of patients and providers towards using a remote wound monitoring application. Methods: This formative descriptive qualitative study reports the result of analysis of the interview content of five patients and five providers from a colorectal surgery clinic at the Medical University of South Carolina in Charleston, South Carolina. Semi-structured, face-to-face interviews were conducted in the clinic setting, were recorded, and professionally transcribed. Two of the authors independently reviewed and coded the transcribed interviews to identify themes across all 10 interviews. After independent coding, authors reviewed findings to reconcile and streamline the primary themes representing attitudes of patients and providers toward remote wound monitoring. Results: Five primary codes were found across our interviews: current barriers, infection types, workflow, interest in surgical site infection (SSI) monitoring, application considerations, and requested application features. We subcoded "symptom clarification" and "positive anticipation" under "interest in SSI monitoring," as well as "anticipated issues" and "application features" under "application considerations." From these codes, we synthesized findings into three overarching themes: smartphone app for remote wound monitoring has potential to improve patient-provider communication, specific wound evaluation processes are acceptable to patients and providers, and new collaboration with telehealth service is a welcome addition for interdisciplinary team management. Conclusions: A prospective approach to the development of a remote wound monitoring application enables a user-centric development process. Our analysis shows a readiness from both patients and providers to implement remote wound monitoring for identifying potential SSIs and coordinating surgical wound care within the community.

A Qualitative Protocol to Examine Resilience Culture in Healthcare Teams during COVID-19.

Resilience allows teams to function at their optimal capacity and skill level in times of uncertainty. The SARS-CoV-2 (COVID-19) pandemic created a perfect opportunity to study resilience culture during a time of limited healthcare team experience, protocols, and specific personal protective equipment (PPE) needed. Little is known about healthcare team resilience as a phenomenon; existing definitions and empiric referents do not capture the nature of healthcare team resilience, as the traditional focus has been placed on individual resilience. This qualitative research protocol provides the rationale and methodology to examine this phenomenon and builds a bridge between resilience engineering and individual resilience. The sample is composed of healthcare team members from the US. This research may add to the body of knowledge on resilience culture in healthcare teams during the COVID-19 pandemic. This qualitative research protocol paper outlines the rationale, objective, methods, and ethical considerations entailed in this research.

Prevention of Failure to Rescue in Obstetric Patients: A Realist Review.

BACKGROUND: At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue. AIMS: To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events. METHODS: A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety. RESULTS: Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork. LINKING EVIDENCE TO ACTION: Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.

Acceptability of a Mobile-Health Living Kidney Donor Advocacy Program for Black Wait-Listed Patients.

Marked racial disparities exist in rates of living donor kidney transplantation (LDKT). The Living Organ Video Educated Donors (LOVED) program is a distance-based, mobile health program designed to help Black kidney transplant wait-list patients advocate for a living donor. This study reported on the acceptability outcomes to aid in future refinements. Participants were randomized to LOVED (n = 24, mean age = 50.9 SD (9.2) years), male = 50%) and usual care groups (n = 24 (mean age 47.9 SD (10.0), male 50%). Four LOVED groups completed an eight-week intervention that consisted of six online video education modules and eight group video chat sessions led by a Black navigator. Qualitative analysis from post-study focus groups resulted in six themes: (1) video chat sessions provided essential support and encouragement, (2) videos motivated and made participants more knowledgeable, (3) connectivity with tablets was acceptable in most areas, (4) material was culturally sensitive, (5) participation was overall a positive experience and (6) participants were more willing to ask for a kidney now. The video chat sessions were pertinent in participant satisfaction, though technology concerns limited program implementation. Results showed that the LOVED program was acceptable to engage minorities in health behavior changes for living donor advocacy but barriers exist that require future refinement.

A distance-based living donor kidney education program for Black wait-list candidates: A feasibility randomized trial.

Addressing racial disparities in living donor kidney transplants (LDKT) among Black patients warrants innovative programs to improve living donation rates. The Living Organ Video Educated Donors (LOVED) program is a 2-arm, culturally-tailored, distance-based, randomized controlled feasibility trial. The group-based, 8-week program used peer-navigator led video chat sessions and web-app video education for Black kidney waitlisted patients from United States southeastern state. Primary feasibility results for LOVED (n = 24) and usual care (n = 24) arms included LOVED program tolerability (i.e., 95.8% retention), program fidelity (i.e., 78.9% video education adherence and 72.1% video chat adherence). LDKT attitudinal and knowledge results favored the LOVED group where a statistically significant effect was reported over 6-months for willingness to approach strangers (estimate ± SE: -1.0 ± .55, F(1, 45.3) = 7.5, P = .009) and self-efficacy to advocate for a LDKT -.81 ± .31, F(1, 45.9) = 15.2, P < .001. Estimates were improved but not statistically significant for willingness to approach family and friends, LDKT knowledge and concerns for living donors (all P's > .088). Secondary measures at 6 months showed an increase in calls for LOVED compared to usual care (P = .008) though no differences were found for transplant center evaluations or LDKTs. Findings imply that LOVED increased screening calls and attitudes to approach potential donors but feasibility outcomes found program materials require modification to increase adherence.

Barriers Associated with the Implementation of Homework in Youth Mental Health Treatment and Potential Mobile Health Solutions.

BACKGROUND: Homework, or between-session practice of skills learned during therapy, is integral to effective youth mental health TREATMENTS. However, homework is often under-utilized by providers and patients due to many barriers, which might be mitigated via mHealth solutions. METHODS: Semi-structured qualitative interviews were conducted with nationally certified trainers in Trauma Focused Cognitive Behavioral Therapy (TF-CBT; n=21) and youth TF-CBT patients ages 8-17 (n=15) and their caregivers (n=12) to examine barriers to the successful implementation of homework in youth mental health treatment and potential mHealth solutions to those barriers. RESULTS: The results indicated that many providers struggle to consistently develop, assign, and assess homework exercises with their patients. Patients are often difficult to engage and either avoid or have difficulty remembering to practice exercises, especially given their busy/chaotic home lives. Trainers and families had positive views and useful suggestions for mHealth solutions to these barriers in terms of functionality (e.g., reminders, tracking, pre-made homework exercises, rewards) and user interface (e.g., easy navigation, clear instructions, engaging activities). CONCLUSIONS: This study adds to the literature on homework barriers and potential mHealth solutions to those barriers, which is largely based on recommendations from experts in the field. The results aligned well with this literature, providing additional support for existing recommendations, particularly as they relate to treatment with youth and caregivers.

Feasibility of Breast Radiation Therapy Video Education Combined With Standard Radiation Therapy Education for Patients With Breast Cancer.

OBJECTIVES: To determine the feasibility of incorporating a brief animated educational video shown during the radiation therapy (RT) consultation appointment for patients with breast cancer and to collect preliminary quality-of-life data. SAMPLE & SETTING: 20 participants with breast cancer were recruited from an outpatient radiation oncology facility in the southeastern United States. METHODS & VARIABLES: This single-arm, pre- and post-test feasibility study aimed to assess feasibility and preliminary outcomes of patient-reported anxiety, distress, and RT concerns. RESULTS: The video intervention demonstrated feasibility, as evidenced by meeting or exceeding benchmarks set for recruitment, retention, and feasibility measured scores. The difference in means of total patient-reported scores comparing pre- to postintervention decreased. IMPLICATIONS FOR NURSING: The intervention proved feasible. In addition, the decrease in total mean scores suggests the video may have a positive effect on reducing patient distress, anxiety, and RT concerns.

Using Flow Disruptions to Examine System Safety in Robotic-Assisted Surgery: Protocol for a Stepped Wedge Crossover Design.

BACKGROUND: The integration of high technology into health care systems is intended to provide new treatment options and improve the quality, safety, and efficiency of care. Robotic-assisted surgery is an example of high technology integration in health care, which has become ubiquitous in many surgical disciplines. OBJECTIVE: This study aims to understand and measure current robotic-assisted surgery processes in a systematic, quantitative, and replicable manner to identify latent systemic threats and opportunities for improvement based on our observations and to implement and evaluate interventions. This 5-year study will follow a human factors engineering approach to improve the safety and efficiency of robotic-assisted surgery across 4 US hospitals. METHODS: The study uses a stepped wedge crossover design with 3 interventions, introduced in different sequences at each of the hospitals over four 8-month phases. Robotic-assisted surgery procedures will be observed in the following specialties: urogynecology, gynecology, urology, bariatrics, general, and colorectal. We will use the data collected from observations, surveys, and interviews to inform interventions focused on teamwork, task design, and workplace design. We intend to evaluate attitudes toward each intervention, safety culture, subjective workload for each case, effectiveness of each intervention (including through direct observation of a sample of surgeries in each observational phase), operating room duration, length of stay, and patient safety incident reports. Analytic methods will include statistical data analysis, point process analysis, and thematic content analysis. RESULTS: The study was funded in September 2018 and approved by the institutional review board of each institution in May and June of 2019 (CSMC and MDRH: Pro00056245; VCMC: STUDY 270; MUSC: Pro00088741). After refining the 3 interventions in phase 1, data collection for phase 2 (baseline data) began in November 2019 and was scheduled to continue through June 2020. However, data collection was suspended in March 2020 due to the COVID-19 pandemic. We collected a total of 65 observations across the 4 sites before the pandemic. Data collection for phase 2 was resumed in October 2020 at 2 of the 4 sites. CONCLUSIONS: This will be the largest direct observational study of surgery ever conducted with data collected on 680 robotic surgery procedures at 4 different institutions. The proposed interventions will be evaluated using individual-level (workload and attitude), process-level (perioperative duration and flow disruption), and organizational-level (safety culture and complications) measures. An implementation science framework is also used to investigate the causes of success or failure of each intervention at each site and understand the potential spread of the interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25284.

Psychosocial functioning in veterans with combat-related PTSD: An evolutionary concept analysis.

BACKGROUND: Veterans returning from combat have a greater risk for developing posttraumatic stress disorder (PTSD) and greater severity of psychosocial functioning impairment. Previous research has demonstrated the strong association between PTSD and psychosocial functioning impairment. Psychosocial functioning is an ambiguous term often used in literature to discuss PTSD-associated consequences, intervention response, and symptom progression. An evolutionary concept analysis was conducted to clarify understanding of psychological functioning in veterans with combat-related PTSD. Rodgers' method for an evolutionary concept analysis was used to examine the concept of psychosocial functioning. A literature search using the Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases and subsequent screening yielded twenty articles meeting established criteria for analysis. The analysis highlights significant attributes, antecedents, consequences, and implications for future concept development. Psychosocial functioning environment/domain, social support, and engagement in treatment were distinguishing attributes identified. Combat exposure and various PTSD symptoms are related antecedents. Consequences such as decreased intimacy, decreased work function, low parenting satisfaction, and inadequate productivity in educational settings are all components of this concept. The concept of psychosocial functioning is meaningful in the everyday lives of US combat veterans with PTSD and requires special consideration in treatment planning by healthcare providers.

What Do Neonatal Intensive Care Unit Policies Tell Us About Kangaroo Care implementation? A Realist Review.

BACKGROUND: Kangaroo care (KC) is recommended for infants during their stay in the neonatal intensive care unit (NICU) due to the benefits to infant growth, stabilized vital signs, and parental bonding; however, literature primarily explores the physiologic benefits, barriers, and facilitators to KC practice. Little is known about the context and mechanisms of KC implementation. PURPOSE: This realist review is to explore what NICU policies tell us about practices to implement KC in the NICU. METHODS: Policies were obtained via email, database, and search engines. Criteria were established to review each policy. Data were entered into a database then exported for frequency counts of identified characteristics. RESULTS: Fifty-one policies were reviewed, which revealed inconsistencies in the implementation of KC practices. Inconsistencies include variability in infant postmenstrual ages and weight criteria, infant medical equipment in place during participation, duration and frequency of KC, KC documentation, and ongoing monitoring requirements. IMPLICATIONS FOR PRACTICE: KC implementation varies widely across NICUs, even with similar infant populations. Exclusion of some infants from receiving KC may decrease the potential beneficial outcomes known to result from KC. IMPLICATIONS FOR RESEARCH: More research to understand KC best practice recommendations and implementation in the NICU is needed. Studies are needed to evaluate the duration and frequency of KC, as well as the benefits to infants and families to optimize KC in the NICU setting.

Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods.

The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31-40.].

Breast Cancer Survivors' Unmet Needs After Completion of Radiation Therapy Treatment.

PURPOSE: To identify the unmet needs of breast cancer survivors after radiation therapy. PARTICIPANTS & SETTING: Patients who received radiation therapy for unilateral breast cancer with six months or longer of follow-up and exhibited no disease progression were eligible for selection to a study conducted at an outpatient radiation therapy academic practice in the southeastern United States. METHODOLOGIC APPROACH: A qualitative descriptive study was undertaken using semistructured interviews, framed by the five domains of the Survivor Unmet Needs Survey and analyzed using an iterative inductive and deductive process. FINDINGS: Of the 24 invited patients, 17 agreed to the interview (including one male patient). Themes emerged from the emotional, relationships, and information needs domains. IMPLICATIONS FOR NURSING: Healthcare providers should perform a comprehensive needs assessment for patients with breast cancer receiving radiation therapy. Self-management assessment instruments may address patients' confidence in managing all phases of radiation therapy side effects.

Negative Behavior Among Healthcare Professionals: Integrative Review of Instruments.

BACKGROUND: Behaviors that undermine a culture of safety pose a serious threat to the overall wellbeing of healthcare workers as well as to patient outcomes. PURPOSE: The purpose of this integrative review is to compare reported psychometrics, feasibility, and identify commonalities among available instruments measuring negative behaviors among healthcare professionals. METHODS: Whittemore and Knafl's integrative review methods were used to analyze pertinent instruments designed to measure negative behaviors among healthcare professionals. Multiple computerized databases including CINAHL, MEDLINE, and Scopus databases were searched in the fall of 2017 without date restrictions. RESULTS: Violence, incivility, and bullying are the most frequently measured behaviors in healthcare workers, and a robust number of valid and reliable instruments are available. CONCLUSIONS: To date a comprehensive review of psychometric properties and feasibility of administration is lacking. This review synthesizes the instruments measuring these behaviors, providing a resource for future research focused on mitigation and intervention strategies.