Effects of a medication adherence app among medically underserved adults with chronic illness: a randomized controlled trial.

For individuals living with a chronic illness who require use of long-term medications, adherence is a vital aspect of successful symptom management and outcomes. This study investigated the effect of a smartphone app on adherence, self-efficacy, knowledge, and medication social support in a medically underserved adult population with various chronic illnesses. Participants were randomized to a group who used the app for one month or a control group provided with a printed medication list. Compared to the control group, participants receiving the intervention had significantly greater medication adherence (Cohen's d = -0.52, p = .014) and medication self-efficacy (Cohen's d = 0.43, p = .035). No significant effects were observed related to knowledge or social support. The findings suggest use of the app could positively impact chronic disease management in a medically underserved population in the United States.

Auricular Acupressure Adjunct Treatment for Opioid Tapering: A Randomized Pilot Feasibility Study.

PURPOSE: Opioid medications are necessary in the treatment of critically ill infants; however. prolonged use may lead to withdrawal syndrome. The purpose of this study was to assess feasibility of delivering an acupressure protocol for the treatment of iatrogenic withdrawal in a pediatric cardiac intensive care unit as well as impact and acceptance of acupressure as an adjunct treatment. DESIGN: Randomized pilot feasibility trial. METHODS: Acupressure stickers were applied and rotated to one ear every 1-3 days until withdrawal symptoms improved. RESULTS: There were no serious adverse events, with only one reported incident of skin irritation. Recruiting benchmarks were exceeded. Weaning phases were significantly shorter in the acupressure group (medians 6.0 vs 22.0 respectively, p = .025, d = 0.90) and the control group used skin-to-skin contact as a comfort measure significantly more than the acupressure group (42.9% vs 6.3%, p = .18). Acupressure was accepted by parents, with an overall 96.2% rating their experience as positive, as measured by the Parent Client Satisfaction Questionnaire. The majority of health care providers (n = 19) were supportive, with 71.9% agreeing or completely agreeing acupressure is an acceptable adjunct for the treatment of withdrawal symptoms; 26.8% were neutral, as measured by the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure. CONCLUSIONS: Acupressure was found to be safe, feasible, and accepted by health care providers in a pediatric cardiac intensive care setting. CLINICAL IMPLICATIONS: These findings support future research with larger sample sizes to improve clinical treatment of infants physically dependent on sedative medications.

Small Patients but a Heavy Lift: Workload and Burnout of Advanced Practice Providers and Physicians in a Level IV Neonatal Intensive Care Unit.

OBJECTIVE: This study explored the association between workload and the level of burnout reported by clinicians in our neonatal intensive care unit (NICU). A qualitative analysis was used to identify specific factors that contributed to workload and modulated clinician workload in the NICU. STUDY DESIGN: We conducted a study utilizing postshift surveys to explore workload of 42 NICU advanced practice providers and physicians over a 6-month period. We used multinomial logistic regression models to determine associations between workload and burnout. We used a descriptive qualitative design with an inductive thematic analysis to analyze qualitative data. RESULTS: Clinicians reported feelings of burnout on nearly half of their shifts (44%), and higher levels of workload during a shift were associated with report of a burnout symptom. Our study identified 7 themes related to workload in the NICU. Two themes focused on contributors to workload, 3 themes focused on modulators of workload, and the final 2 themes represented mixed experiences of clinicians' workload. CONCLUSION: We found an association between burnout and increased workload. Clinicians in our study described common contributors to workload and actions to reduce workload. Decreasing workload and burnout along with improving clinician well-being requires a multifaceted approach on unit and systems levels.

The Social Ecology of Burnout: A framework for research on nurse practitioner burnout.

BACKGROUND: The U.S. health system is burdened by rising costs, workforce shortages, and unremitting burnout. Well-being interventions have emerged in response, yet data suggest that the work environment is the problem. Nurse practitioner (NP) burnout is associated with structural and relational factors in the work environment, practice autonomy, and hierarchical leadership. PURPOSE: We explore the unique social, cultural, and political environment in which NPs work through the lens of social ecology and present the Social Ecology of Burnout (SEB) framework. METHODS: We review current burnout frameworks in the context of the NP practice environment and discuss the SEB, specifically exploring psychological safety and its influence on burnout. FINDINGS: Psychological safety, work environment, and policy are presented within the SEB and solutions which empower NPs are considered. DISCUSSION: Our framework can serve as a guide for future nursing research, practice, and policy.

"I had no choice": A mixed-methods study on access to care for vaginal breech birth.

INTRODUCTION: Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth. METHODS: We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care. RESULTS: Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system. CONCLUSION: Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Postoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery.

PURPOSE: The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery. DESIGN AND METHODS: This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS. RESULTS: We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (rs = -.57, p = .017) in children with single ventricle physiology. CONCLUSIONS: Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology. PRACTICE IMPLICATIONS: Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.

People Living With Dementia: Dementia Characteristics and Family Caregiver Pain Assessment.

People living with dementia (PLWD) experience pain like other older adults, but with changes due to dementia, they rely more on family caregivers for pain assessment. Many different elements contribute to a pain assessment. Changes in characteristics of PLWD may be associated with changes in the use of these different pain assessment elements. The current study reports associations between PLWD's agitation, cognitive function, and dementia severity and the frequency with which family caregivers use pain assessment elements. In a sample of family caregivers (N = 48), statistically significant associations were found between worsening cognitive function and greater use of rechecking for pain after intervention (rho = 0.36, p = 0.013), and between lower cognitive scores on a subscale of dementia severity and asking others if they have noticed a behavior change in the PLWD (rho = 0.30, p = 0.044). Limited statistically significant associations suggest that, overall, family caregivers of PLWD do not use pain assessment elements more frequently with changes in characteristics of PLWD. [Journal of Gerontological Nursing, 49(7), 17-23.].

Readiness to Plan for Aging and Frailty: Examining Contextual Factors.

As older adults live longer, individual and societal efforts must be directed toward strategies to promote healthy and successful aging. Planning for aging and frailty offers an opportunity for older adults to optimize their well-being and proactively prepare across their aging trajectory. The current study evaluated the relationship between contextual factors (functional status, frailty, health status, social support) that influence older adults' readiness to engage in planning in five domains of aging (communication, environmental, financial, physical care, cognitive) through the transtheoretical stages of change. Results showed that factors influencing active planning include older age, vulnerability, living situation, and social support. These results add to the discourse on future care planning through a comprehensive approach to planning across a life course perspective, while highlighting the importance of future research at individual and societal levels. Gerontological nurses are well-positioned to lead planning efforts for older adults that promote well-being, patient-centered care, and healthy aging. [Journal of Gerontological Nursing, 49(2), 27-35.].

Development and preliminary validation of a health-related family quality of life instrument.

The researchers' aims for this preliminary study was to develop an instrument, guided by the Theory of Health-related Family Quality of Life, to measure health-related family quality of life (HR-FQoL) as perceived by women with cancer. The researchers used a two phase design for instrument development: (1) establishing face validity of a 38-item instrument with an expert panel and patient review, and (2) focusing on the internal structure and construct validity of the instrument with responses from female patients (N = 236) with a cancer diagnosis (breast, gynecologic). The researchers identified a final 25-item HR-FQoL instrument with four sub-scales that each captured multiple concepts within the Theory of HR-FQoL. The resulting instrument maybe used by researchers and clinicians to assess various aspects of health-related family quality of life among female breast and gynecological cancer survivors.

Caregiving self-efficacy and pain assessment by family caregivers of people living with dementia.

Like other older adults, people living with dementia (PLWD) experience pain, and the task of pain assessment often falls to family caregivers. In this study, we surveyed family caregivers of PLWD to determine the frequency with which they use different elements of pain assessment. We also determined correlations of family caregivers' characteristics (caregiving self-efficacy, relationship duration and type, mood, education level, and health literacy) with their use of the elements of pain assessment. Participants reported frequent use of many pain assessment elements. Statistically significant correlations were found between caregiving self-efficacy for obtaining respite and asking others about noticed behavior change (rho=.0.41, p=.007); and for responding to disruptive patient behaviors for multiple pain assessment elements including observing pain behaviors (rho=0.49, p<.001), asking others about noticed behavior change (rho=0.54, p<.001) and rechecking (rho=0.56, p<.001). Continued efforts are needed to describe pain assessments by family caregivers of PLWD.

The impact of COVID on end-of-life planning views, social connection, and quality of life for low-income, older adults: A qualitative study.

OBJECTIVES: Low-income, older adults are less likely than those with high income to participate in advance care planning (ACP); however, the pandemic may have influenced their views. The aim of this report was to explore the perceptions of COVID-19 related to everyday life and ACP. METHODS: We embedded ACP behavior inequities within the Social Ecological Model to highlight the importance of considering social inequities within an environmental context. Using a qualitative descriptive design, twenty individual interviews were conducted. Thematic analysis consisted of multiple rounds of independent and iterative coding by 2 coders that resulted in a hierarchically organized coding system. Final themes emerged through the inductive consideration of the transcript data and the deductive contribution of our theoretical framework. RESULTS: Three major themes emerged: social connection, quality of life, and end-of-life planning views. COVID-19 had not changed ACP views, i.e., those with existing ACP maintained it and those without ACP still avoided planning. SIGNIFICANCE OF RESULTS: Low-income, older adults experienced lower social connection and quality of life during COVID-19 but did not express changes to ACP views. Our findings of the loss of regular social practices and mental health struggles may have competed with participants' perception that this crisis had little, if any, effect on ACP. While clinicians should monitor low-income, older adults for ACP barriers during COVID-19, policymakers should prioritize ACP at the systems level. We plan to use participatory research methods to explore for the minimal ACP impact, focusing on barriers to ACP opportunities.

Caregivers' experience with Tele-Savvy Caregiver Program post-hospitalization.

Despite the frequent hospitalizations and readmissions of persons living with dementia (PLWD), no telehealth transitional care interventions focus on PLWDs' unpaid caregivers. Tele-Savvy Caregiver Program is a 43-day evidence-based online psychoeducational intervention for PLWDs' caregivers. The aim of this formative evaluation was to explore caregivers' acceptability of and experience with their participation in Tele-Savvy after their PLWDs' hospital discharge. Additionally, we gathered caregivers' feedback on the recommended features of a transitional care intervention, suitable for caregivers' schedule and needs post-discharge. Fifteen caregivers completed the interviews. Data were analyzed via conventional content analysis. Four categories were identified: (1) Tele-Savvy improved participants' understanding of dementia and caregiving; (2) hospitalization started a "new level of normal"; (3) PLWDs' health concerns; and (4) transitional care intervention development. Participation in Tele-Savvy was acceptable for most caregivers. Participants' feedback provides content and structural guidance for the development of a new transitional care intervention for PLWDs' caregivers.

Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation.

INTRODUCTION: This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department. METHODS: An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome. RESULTS: Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions. DISCUSSION: Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.

Trauma Patient Transitions From Critical Care: A Survey of U.S. Trauma Centers.

BACKGROUND: Transitions between clinical units are vulnerable periods for patients. A significant body of evidence describes the importance of structured transitions, but there is limited reporting of what happens. Describing transitions within a conceptual model will characterize the salient forces that interact during a patient transition and, perhaps, lead to improved outcomes. OBJECTIVE: To describe the processes and resources that trauma centers use to transition patients from critical care to nonintensive care units. METHODS: This cross-sectional study surveyed all Level I and II trauma centers listed in the American Trauma Society database from September 2020 to November 2020. Data were merged from the American Hospital Association 2018 Hospital Survey. RESULTS: A total of 567 surveys were distributed, of which 152 responded for a (27%) response rate. Results were organized in categories: capital input, organizational facets, employee behavior, employee terms/scope, and labor inputs. Resources and processes varied; the most important opportunities for transition improvement included: (1) handoff instruments were only reported at 36% (n = 27) of trauma centers, (2) mandatory resident education about transitions was only reported at 70% (n = 16) of trauma centers, and (3) only 6% (n = 4) of trauma centers reported electronic medical record applications that enact features to influence employee behavior. CONCLUSIONS: After years of focusing on transitions as a high-stake period, there remain many opportunities to develop resources and enact effective processes to address the variability in transition practice across trauma centers.

Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention.

BACKGROUND: To evaluate risk factors (treatment-related, comorbidities, and lifestyle) for breast cancer-related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL. METHODS: The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L-Dex ≥6.5 or tape volume ≥ 5% and < 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni-corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance. RESULTS: The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p < .001), taxane-based chemotherapy (p < .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index >30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk. CONCLUSIONS: Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane-based chemotherapy, RNI, body mass index >30, and rurality increased risk.

Subjective Cognition Reported by Caregivers Is Correlated With Objective Cognition in Liver Transplant Recipients.

Objective cognitive assessments, a gold standard diagnostic tool for cognitive impairment, may not be feasible in busy liver transplantation (LT) practice because they are often time consuming. This study determined whether subjective cognition, patients' self-ratings and/or caregivers' ratings of patients' cognition, reflects objective cognition in LT recipients. A convenience sample of 60 adult LT recipients and their caregivers, recruited at a single transplant center, participated in this cross-sectional descriptive study. Subjective cognition (ie, recipient self-rated and caregiver rated) was measured using the Everyday Cognition (ECog; global and 6 domain scores). Objective global and domain-specific cognition of recipients was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test parts A and B, Digit Span Backward, and Rey-Osterrieth Complex Figure. Agreement between LT recipients' ECog scores and those of their caregivers was fair to moderate (intraclass correlation coefficient = 0.48 for global score, 0.35-0.56 for domain scores). Significant, albeit rather weak, correlations were found between subjective and objective scores. Recipients' ECog visuospatial abilities scores were correlated with Rey-Osterrieth Complex Figure scores (rs  = -0.39; P = 0.007), whereas caregivers' ECog global, attention, visuospatial abilities, and organization scores were, respectively, correlated with the scores of RBANS global (rs  = -0.33; P = 0.04) and attention (rs  = -0.46; P = 0.005), Rey-Osterrieth Complex Figure (Copy; rs  = -0.34; P = 0.03), and Trail Making Test part A (rs  = 0.31; P = 0.049). The findings suggest that caregivers may estimate LT recipients' cognition better than recipients themselves. Caregivers may provide supplemental information that could be useful for clinicians when considering the cognitive functioning of LT recipients.

A Cross-Sectional Study of Pain Sensitivity and Unpleasantness in People with Vascular Dementia.

OBJECTIVE: Advanced age is associated with a higher risk of both pain and dementia, with many studies finding that dementia often heightens sensitivity to pain. Vascular dementia (VaD) is the second most common type of dementia. Only a few observational or retrospective studies have examined pain responsiveness in VaD, suggesting that it could increase pain unpleasantness (i.e., pain affect). This study compared thermal pain psychophysics between a cohort of patients with VaD and healthy control (HC) subjects. DESIGN: Single-center, cross-sectional, between-subjects design. SUBJECTS: Verbally communicative patients with probable VaD (n = 23) and age- and sex-matched HCs (n = 23). METHODS: A thermal psychophysics protocol assessed "mild pain" and "moderate pain" thresholds (temperature in degrees Celsius) and associated unpleasantness ratings (0-20 scale) in both the VaD and HC groups. Psychophysics were compared between groups by way of a mixed-effects analysis, controlling for depressive symptoms. RESULTS: There were no significant differences between groups for pain thresholds (main effect P = 0.086, Cohen's d: mild = 0.55, moderate = 0.27). However, unpleasantness ratings were higher in the VaD group than in the HC group (main effect P = 0.003; mild pain P = 0.022, Cohen's d = 0.79; moderate pain P = 0.057, Cohen's d = 0.6). CONCLUSIONS: These results are consistent with prior observational findings suggesting that VaD could make patients more susceptible to pain, particularly its affective component.

Choking, allergic reactions, and pickiness: A qualitative study of maternal perceived threats and risk avoidance strategies during complementary feeding.

An infant's early eating experiences influence later growth and health. However, motivators for mothers' complementary feeding decisions for their infants, such as the process of introducing solid foods, remains unclear. This qualitative study identified maternal perceived threats surrounding complementary feeding and strategies mothers use to mitigate perceived threats of adverse feeding-related health outcomes for their infants. Twenty-seven mothers participated in private, semi-structured interviews. Inductive and deductive qualitative content analysis revealed three primary themes of maternal perceived threats: a) choking, b) allergic reaction, and c) pickiness. Within each primary theme were sub-themes that further delineated the perceived threats and outlined specific and focused complementary feeding practices (CFPs) mothers used for each type of perceived threat. Findings suggest mothers have difficulty with estimating the likelihood and severity of risks and rely on elevated threat perception to guide their feeding decisions. CFPs used to prevent perceived threats were disproportionate to risks, and, at times, actually introduced additional, alternative risks.

The Development, Preliminary Validation, and Clinical Application of the Quick Parenting Assessment.

To prevent diseases, efforts are needed to determine how to address Adverse Childhood Experiences (ACEs), including parenting behaviors. The objective of this study, conducted in Nashville TN in 2017, was to initiate testing the psychometric properties of two new Adverse Childhood Experiences (ACEs) screening tools, the Quick Parenting Assessment (QPA) and Other Childhood Stressors (OCS). In a clinic serving low-income families, caregivers of children ages 2-10 completed assessments of parenting (QPA), other stressors (OCS), child behavior problems ((Strength and Difficulties Questionnaire (SDQ)), and Attitudes Toward Spanking (ATS). The QPA takes 1 min to complete and assesses for healthy and unhealthy parenting behaviors. Seventy-five percent of eligible participants completed the survey (N=558). A reduced 10-item QPA yielded a Cronbach's alpha of 0.79 and, in 4-10-year-olds, was associated with high SDQ conduct, hyperactivity, and total difficulties scores (r=0.44, 0.48, and 0.47; all p< 0.001). Children with QPAs of >4 were nine times more likely than those children with scores of ≤2 to have behavior problems (OR=8.93, 95% CI = 3.74-21.32). Elevated QPAs were associated with the ATS (r=0.47, p < .001). The OCS was also associated with high SDQ total difficulties scores (r=0.28, p< 0.001). Two pediatric ACEs screening tools, the QPA and the OCS, have promising psychometric properties. The findings suggest that parenting behaviors may play an outsized role in the pathogenesis of outcomes associated with ACEs. We discuss the clinical application of QPA at our institution and the theoretical potential for this instrument to reduce the rates of short- and long-term health problems.

PLAN: Preparing and Living for Aging Now; A descriptive study investigating older adults' readiness to plan for aging and frailty.

OBJECTIVES: Many older adults want to age in place but do not make plans. Understanding how and under what conditions adults prepare/plan ahead is vital given population aging and increasing frailty. This study examines the stages of change and experiences (personal/others) related to readiness to plan for aging and frailty. METHODS: Descriptive cross-sectional. SETTING: Community-dwelling. PARTICIPANTS: Adults aged 50-80(N = 252). DATA COLLECTION: demographics, other characteristics, stages of change, experiences (personal/others) was assessed with survey questions. DATA ANALYSIS: frequencies/percentages, McNemar test, Chi-square. RESULTS: Among domains, participants' percentages in action/maintenance stages ranged from 28.2% (cognitive) to 68.7% (financial). Participants had increased experience with others across domains rather than self. Older participants (≥ 70) vs. younger (50-69) reported statistically significant greater planning in action/maintenance stages for all domains (p < .05) with the exception of cognitive. DISCUSSION: Examining the concept of planning for aging and frailty provides a foundation for future work to develop/test interventions aimed at increasing readiness for aging.