The transformative power of participating in Opening Minds Through Art (OMA), an expressive arts program for medical students.

Opening Minds Through Art (OMA) is a standardized expressive arts-based program that improves student attitudes toward persons living with dementia. Understanding how this change occurs is important for both educators and clinicians. In this study, narrative analysis was used to explore the impact of OMA on participating medical students. 111 students at six medical schools accepted an invitation to be part of OMA during the 2018-2020 academic years. After completing the program, participants were asked to write briefly about the impact of their OMA experience on their work as future physicians. These narratives were analyzed to identify themes relevant to the impact of the program. Students described appreciating both pragmatic and novel creative experiences in OMA, which differed from their traditional studies. Themes from the evaluation included: Inter and Intrapersonal Connection and Growth; Mastery of Anticipated Challenges; Acquisition of Knowledge and Skills; and Appreciation of Health Care Team Members. Teaching students to embrace clinical work with challenging and perceived "difficult" patients is often unaddressed in the medical school curriculum. This study suggests that the combination of medical knowledge and artistic expression can be used to benefit both students and persons living with dementia.

The Impact of an Unconventional Elective in Narrative Medicine and Pediatric Psycho-oncology on Humanism in Medical Students.

Over the course of medical school, students' optimism and hopefulness often devolve into a cynical view of medicine that continues throughout clinical rotations and beyond (Neumann et al., Acad Med 86(8):996-1009, 2011). Here, we present a qualitative evaluation of a novel immersive elective in pediatric psycho-oncology coupled with narrative medicine and its impact on students. Participants were third- and fourth-year medical students who were relieved of traditional clinical duties. Alternatively, they shadowed pediatric cancer patients, keeping narrative journals of their observations and insights. A trained team of pre-clinical medical students and faculty conducted a retrospective analysis of 120 journals written between 2008 and 2019. They compared recurring concepts to assess how blending experiential learning and reflective writing influenced the attitudes and behaviors of students. Consistent themes emerged related to developing a rich understanding of patient experiences, a humanistic appreciation of the context of illness, the ability to meaningfully reflect on insights to critically ill children, and an appreciation for the unique learning opportunity. Additionally, families expressed gratitude for the students' attentiveness to their emotional needs. By the conclusion of the elective, most students discovered that they had reignited their intrinsic empathic behaviors and were provided with beneficial insights that they believed would continue into future rotations. Experiential teaching methods paired with narrative reflection may be a valuable and therapeutic tool to learn the intricacies of the patient perspective, with the potential to enhance humanism in students during a critical time in their medical training when empathy tends to drift. Longitudinal and quantitative studies are warranted to better understand the degree and duration of specific benefits.

De-stressing From Distress: Preliminary Evaluation of a Nurse-Led Brief Debriefing Program.

In critical care units, distressing events related to patient and family-centered care can influence job dissatisfaction and emotional distress.1-8 Strategies for processing difficult incidents are limited, creating a need for standardized real-time debriefing tools. This study evaluated an innovative nurse-led program that was developed and piloted in one acute care unit of a large academic medical center. An evidence-based practice nurse-led debriefing process provided a sequential process for facilitation of an interdisciplinary group after the occurrence of a distressing event. Throughout a 2-year period, 104 real-time debriefings (>380 staff participation) took place. Emergent situations precipitated the most debriefings followed by disruptive patient/family behavior. Over 80% of the participants affirmed the debriefing process was beneficial, assisted them in coping with the traumatic event, and recommended this type of debriefing to others. These results show that members of an interdisciplinary team will engage in a brief (∼10 minute) nurse-led debriefing program when offered the opportunity to do so, and that this intervention was successful beyond the acute care unit where it originated.

Nursing ethics in an era of pandemic.

BACKGROUND: The ANA Code of Ethics for Nurses, regularly revised since 1896, may not provide guidance in an era of pandemic and sociopolitical unrest. PURPOSE: This study explored whether the Code of Ethics comprehensively address current nursing challenges. METHODS: 23 nurses participated in six Zoom focus groups to discuss whether provisions were applicable to their current practice. An iterative approach was used to review transcripts independently and then merge findings to identify ethical themes. FINDINGS: Provisions 4, 6, and 8 were most relevant. None of the provisions addressed the guilt secondary to isolating patients from support systems and not being "on the front lines" of COVID care. DISCUSSION: The co-occurring crises of COVID-19 and social unrest created an ethical crisis for many nurses. The Code of Ethics provided a useful guide for framing discussion and formulating strategies for change, but did not eliminate distress during a time of novel challenges.

An exploration of relational aggression in the nursing workplace.

OBJECTIVE: This study provides a 1st look at relational aggression (RA) and the consequences among nurses. BACKGROUND: Interpersonal hostility, bullying, and a toxic work environment (WE) can impact patient care delivery as well as nurses' personal health and job satisfaction. METHODS: The Relational Aggression Assessment Scale, measuring aggressors, victims, and bystanders, was used to measure RA in a sample of 842 nurses. Additional variables measured included a demographic profile, job satisfaction, and intent to leave. RESULTS: Nurses were most likely to identify with victim behaviors, but a minority of nurses reported relying on aggressor behaviors and bystander behaviors. There was a positive correlation among aggressor, victim, and bystander items, suggesting overlap in roles. CONCLUSIONS: A few relationally aggressive individuals can create a toxic WE. Interventions to address RA among nurses must be tested, as well as strategies for improving job satisfaction and promoting healthy WEs through positive relationships.

Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning.

This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.

The negative impact of organizational cynicism on physicians and nurses.

Despite the potentially severe consequences that might result, there is a paucity of research on organizational cynicism within US health care providers. In response, this study investigated the effect of cynicism on organizational commitment, job satisfaction, and interest in leaving the hospital for another job in a sample of 205 physicians and 842 nurses. Three types of cynicism were investigated: trait (dispositional), global (directed toward the hospital), and local (directed toward a specific unit or department). Findings indicate that all 3 types of cynicism were negatively related to affective organizational commitment and job satisfaction, but positively related to interest in leaving. In both nurse and physician samples, cynicism explained about half of the variance in job satisfaction and affective commitment, which is the type of commitment managers are most eager to promote. Cynicism accounted for about a quarter and a third of the variance in interest in leaving the hospital for nurses and physicians, respectively. Trait, global, and local cynicism each accounted for unique variance in affective commitment, job satisfaction, and interest in leaving, with global cynicism exerting the largest influence on each outcome. The implications for managers are that activities aimed at decreasing organizational cynicism are likely to increase affective organizational commitment, job satisfaction, and organizational tenure.

The physician experience of patient to provider prejudice (PPtP).

Background: Patients can demonstrate prejudice and bias toward minoritized physicians in a destructive dynamic identified as PPtP (Patient Prejudice toward Providers). These interactions have a negative impact on the physical and mental well-being of both those who are targeted and those who witness such behaviors. Study purpose: The purpose of this study was to explore the PPtP experiences of attending physicians who identify as a minority based on race, ethnicity, citizenship status, or faith preference. Methods: Qualitative methodology was used to collect data using in-depth interviews. 15 attending physicians (8 male, 7 female, aged 33-55 years) who identified as minorities based on ethnicity, citizenship status, or faith practices were interviewed individually. Interviews were conducted using a guide validated in previous studies and content analysis was performed by two trained researchers to identify themes. Results: Five themes were identified: A Continuum of Offenses, Professional Growth through Adversity, Organizational Issues, Role of Colleagues, and Consequences for Provision of Care. Findings suggest that although attending physicians learned to cope with PPtP, the experience of being treated with bias negatively impacted their well-being and work performance. Attending physicians also felt that white majority medical students sometimes treated them with prejudice but expressed a commitment to protecting vulnerable trainees from PPtP. Conclusion: The experience of PPtP occurs consistently throughout a career in medicine, often beginning in the years of training and persisting into the phase of attending status. This makes it imperative to include strategies that address PPtP in order to successfully recruit and retain minoritized physicians.

The Impact of Patient Prejudice on Minoritized Female Physicians.

Background: Patient bias and prejudice directed against physicians from diverse backgrounds is a frequent occurrence in healthcare. Female physicians have long experienced discrimination in the healthcare system based on their gender alone. The dynamic known as Patient Prejudice toward Providers (PPtP) is disproportionately affecting female physicians because it is frequently compounded by sexism. Aim: The goal of this study was to explore the impact of PPtP on female resident and attending physicians. Methods: Using transcribed one-on-one interviews from a larger study of PPtP affecting resident and attending physicians, ten interviews with female physicians (resident and attending) from diverse ethnic backgrounds and countries of training at a large academic medical center were analyzed. The authors independently reviewed the interviews using an iterative process within and across interviews to inductively identify repeating words, phrases, and concepts relevant to the study aim. Results: Demographics of the ten participants included age (mean 34.6 years), ethnicity (6 Asian, 2 Hispanic, 2 African), and country of training (10% IMG vs. 90% US trained). Four of the interviewees were residents and six were attendings. Themes that emerged from the analysis included experiencing "A Gendered Continuum of Abuse," "Establishing a Higher Standard of Competency," "Overcoming the Stereotype of the White Male Physician," "The Physicality of Self Identity," and "The Need to be Protective of Minoritized Trainees." All participants agreed that these perceptions created an adverse environment at the workplace and impacted on patient care. Conclusions: Discrimination of physicians based on their gender or their race/ethnicity has been reported. This study highlights the compounded effects of patient prejudice on female minoritized physicians. Organizations and individuals should identify and implement strategies to address the impact of PPtP and sexism in order to create an environment where all women can thrive professionally.

Use of social media in graduate-level medical humanities education: two pilot studies from Penn State College of Medicine.

BACKGROUND: Social media strategies in education have gained attention for undergraduate students, but there has been relatively little application with graduate populations in medicine. AIMS: To use and evaluate the integration of new social media tools into the curricula of two graduate-level medical humanities electives offered to 4th-year students at Penn State College of Medicine. METHODS: Instructors selected five social media tools--Twitter, YouTube, Flickr, blogging and Skype--to promote student learning. At the conclusion of each course, students provided quantitative and qualitative course evaluation. RESULTS: Students gave high favourability ratings to both courses, and expressed that the integration of social media into coursework augmented learning and collaboration. Others identified challenges including: demands on time, concerns about privacy and lack of facility with technology. Integrating social media tools into class activities appeared to offer manifold benefits over traditional classroom methods, including real-time communication outside of the classroom, connecting with medical experts, collaborative opportunities and enhanced creativity. CONCLUSIONS: Social media can augment learning opportunities within humanities curriculum in medical schools, and help students acquire tools and skill-sets for problem solving, networking, and collaboration. Command of technologies will be increasingly important to the practice of medicine in the twenty-first century.

Assessment of irritability in school-aged children by pediatric, family practice, and psychiatric providers.

BACKGROUND: Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication. OBJECTIVE: Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability. METHODS: A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed. RESULTS: In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups. CONCLUSION: This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

An exploratory study of the orientation needs of experienced nurses.

The orientation period creates a context for nurses' relationships with their employers, and can adversely affect attrition rates. Although the orientation needs of novice nurses have been detailed, little is known about what might help those with prior experience. Hence, the goal of this study was to explore whether the orientation needs of seasoned nurses are similar to or unique from those of novice nurses. During a 6-month period, the authors used two intensive qualitative methodologies (daily journaling and focus groups) to study three experienced nurses. A tri-phased model of orientation emerged, with learning and support issues unique to experienced nurses identified. Results suggest that orientation programs for experienced nurses should use specific educational strategies and content to promote engagement in a new position.

A Qualitative Study to Assess How Primary Care Versus Psychiatric Providers Evaluate and Treat Pediatric Patients With Irritability.

OBJECTIVE: To determine how primary care versus specialist practitioners assess and treat school-aged children with irritability. METHODS: Seventeen providers from family medicine, pediatrics, and psychiatry participated in in-depth interviews from June to August 2016 about the process they use to evaluate irritability. Data on demographic traits and measures of confidence were also collected. RESULTS: Primary care (family medicine and pediatrics) participants expressed frustration over the lack of time and specialized knowledge they had to accurately assess children with irritability, even though they were often the first clinician consulted when problems arose. There were clear and sometimes contradictory differences between how practitioners with a general versus specialized practice assessed mental health status in the clinic setting. Input on treatment approaches revealed that medication prescription was more common by primary care participants, and therapy was preferred by the psychiatry participants. CONCLUSIONS: Overall, family medicine and pediatric practitioners were significantly less confident in their ability to evaluate mental health status, while child and adolescent psychiatry participants were supportive of having more initial triage and possible treatment occur at the primary care level, suggesting a need for more training about childhood irritability in the primary care setting.

An Interprofessional Curriculum to Advance Relational Coordination and Professionalism in Early-Career Practitioners.

Introduction: We created a curriculum to help new physicians and nurses develop skills in interprofessional collaboration. This modular, team-based curriculum for early practitioners delivered training in the five following skill areas: listening for meaning, soliciting another's perspective, negotiating a transparent plan of care, attending to nonverbal communication and microaggression, and speaking up the hierarchy. Methods: We brought first-year medical and surgical residents and new nurses together for a 2-hour session monthly for 5 months. Each session began with an interactive large-group presentation, followed by small-group activities covering one of the five skill areas above, which had been identified as critical to interprofessional collaboration by national organizations. We measured relational coordination (RC), a validated measure of how well teams work together, before and after the curriculum was administered. We also obtained qualitative data from participant interviews and end-of-session evaluations. Results: Participants reported that the program helped them gain an understanding of each other's roles and workflow challenges. They felt that the curriculum allowed for the cultivation of professional relationships outside the clinical environment, which improved collegiality via gains in rapport and empathy towards each other. Nurses noted increased approachability of their physician colleagues after participation. RC scores improved for the entire cohort (p = .0232). Nurses had statistically higher RC gains than interns did (p = .0055). Discussion: Curriculum participants demonstrated improved RC scores and reported increased rapport with and empathy for each other. Curriculum development in this area is important because it may lead to better team-based patient care.

The humanities interface of nursing and medicine.

In the 1970s, the field of medical humanities developed and included ethics, literature, history, integrative medicine, and other topics, most often described from a physician's perspective. During this same period of revolutionary changes in health care, nursing curricula did not seek to emphasize content in humanities, perhaps because stereotypical views of nursing as the "caring profession" made such coursework seem redundant. In 2001, as a result of the Institute of Medicine's call for all health professionals to be educated in interdisciplinary teams, there was a new focus on the importance of interdisciplinary education. Collaborative experiences in the humanities can foster professional relationships that lead to professional growth, promote collaboration, and enhance patient-centered care. The purpose of this article is to describe the relevance of humanities to the interdisciplinary education and practice of health care providers. This article extends the thinking about the value of interdisciplinary education beyond the traditional dimensions of evidence-based practice, quality improvement, and informatics to humanities. Ways to provide nurses and physicians with interdisciplinary humanistic experiences are illustrated through an overview of projects jointly developed by the School of Nursing and the College of Medicine at The Pennsylvania State University.

Irritability in Pediatric Patients: Normal or Not?

The goal of this article is to describe the concept of irritability in children and youth, which has been revisited in the DSM-5. Traditionally, this behavior has been more commonly associated with mood disorders, which may account for the rising incidence of bipolar disorder diagnosis and overuse of mood-stabilizing medications in pediatric patients. While not predictive of mania, persistent nonepisodic irritability, if undetected, may escalate to violent behavior with potentially serious outcomes. It is therefore important to educate clinicians about how to accurately assess irritability in pediatric patients.

Caregivers of frail rural older adults. Effects of an advanced practice nursing intervention.

Informal caregivers are responsible for providing the majority of post-discharge care for many frail older adults in rural settings. The purpose of this study was to investigate whether an advanced practice nurse (APN) intervention would promote more positive physical and emotional outcomes in caregivers of rural older adults who are frail and were recently discharged from urban-based hospitals. Thirty-two caregivers of frail rural elderly individuals were randomly assigned to treatment (APN intervention) and control groups (no APN intervention). Assessments of caregiver outcomes were collected via telephone interviews at 48-hour, 2-week, and 4-week intervals after hospital discharge of the frail rural older adults. Outcomes were operationalized as caregiver physical health and well being, and stress and burden. The former was measured using the Health and Daily Living form (HDL) and the latter by the Thoughts and Feeling and Time and Energy subscales of the Caregiver Burden Inventory (CBI). Additional information on caregiver problems and APN visit time was collected by the APN using the Omaha Classification System. Caregivers in the treatment group experienced significantly more positive physical and emotional health outcomes. The caregivers who received the APN intervention had higher self-rated emotional health scores, fewer emotional symptoms at Week 4, fewer depressive symptoms at Week 2 and 4, and lower Thoughts and Feelings stress scores at 48 hours than the control group. Findings support the importance of addressing the needs of caregivers post-discharge and the ability of APNs to improve post-discharge outcomes for home health care recipients and their caregivers.