Are We Teaching Nurses to Be Racist towards Aboriginal and Torres Strait Islander Peoples? A Critical Race Document Analysis of Discrete Aboriginal and Torres Strait Islander Health Courses.

BACKGROUND: Racism is responsible for health inequity and the harm perpetrated upon Aboriginal and Torres Strait Islander peoples by white institutions, building on attitudes and beliefs dominated by assumptions of white superiority. The National Aboriginal and Torres Strait Islander Health Curriculum Framework 'Curriculum Framework', released in 2014, was introduced to provide a framework for nursing programs and included the introduction of discrete Aboriginal and Torres Strait Islander health courses to draw attention to the relationship between racism health outcomes of Aboriginal and Torres Strait Islander peoples within health care settings. METHODS: Using an Indigenist research paradigm with Colonial Critical Race Theory as the methodology and framework, this study presents a document analysis of discrete Aboriginal and Torres Strait Islander health courses taught in undergraduate nursing programs at 31 Australian Universities. RESULTS: This work draws on the collective activism of Aboriginal and Torres Strait Islander nurses in challenging the systemic racism embedded in the Australian nursing curriculum. We demonstrate the utility of the Racial Segregation Audit Tool (RSAT), as an innovative approach to identify and respond to racism embedded in course learning outcomes. CONCLUSIONS: This study explores and uncovers how the learning outcomes assert the social construction of race as a tool of oppressive segregation.

Are Australian Universities Perpetuating the Teaching of Racism in Their Undergraduate Nurses in Discrete Aboriginal and Torres Strait Islander Courses? A Critical Race Document Analysis Protocol.

Systemic racism has a profound negative impact on the health outcomes of Australia's First Nations peoples, hereafter referred to as Aboriginal and Torres Strait Islander peoples, where racism and white privilege have largely become normalised and socially facilitated. A national framework is being mobilised within the tertiary-level nursing curriculum to equip future health professionals with cultural capabilities to ensure culturally safe, equitable health care for Aboriginal and Torres Strait Islander peoples. In 2019, nurses comprised more than half of all registered health professionals in Australia, and current national standards for nursing state that Australian universities should be graduating registered nurses capable of delivering care that is received as culturally safe. It is therefore critical to evaluate where learning objectives within nursing curricula may lead to the reinforcement and teaching of racist ideologies to nursing students. This protocol outlines a framework and methodology that will inform a critical race document analysis to evaluate how learning objectives assert the social construction of "race" as a tool of oppressive segregation. The document analysis will include each discrete Aboriginal and Torres Strait Islander health course within all undergraduate nursing programs at Australian universities. The approach outlined within this protocol is developed according to an Indigenous research paradigm and Colonial Critical Race Theory as both the framework and methodology. The purpose of the framework is a means for improving health professional curriculum by reducing racism as highlighted in nation-wide strategies for curriculum reform.

Effectiveness of structured education and training in perineal wound assessment and repair for midwives and midwifery students: A review of the literature.

INTRODUCTION: Perineal trauma is a commonly observed complication of childbirth, affecting more than 75% of women who have a vaginal birth. Perineal trauma is associated with significant short- and long-term comorbidities that negatively impact women's quality of life. Severe perineal trauma (SPT) rates in Australia have almost doubled in the last decade. Reasons for increased rates are not completely understood; some researchers suggest improvements in diagnosis and reporting, while others have a view that it may be due to a lack of structured and standardized education in perineal wound assessment and repair for clinicians. METHODS: The Joanna Briggs Institute (JBI) scoping review methodology was adopted as a systemic process to identify studies that have investigated the effectiveness of perineal wound assessment and repair education and training for midwives and midwifery students. RESULTS: Five studies met the inclusion criteria for this review, to have evaluated a type of education or training, on childbirth-related perineal wound assessment and repair that included midwives and midwifery students. A total of 1279 midwives and midwifery students volunteered to participate in all five studies. The length of the education or training implemented varied between each study from a 1-day workshop to 100 hours of education. All five studies measured the effectiveness of each program through changes in participants' confidence, knowledge and skills in perineal assessment and repair before and after an intervention using various self-assessment questionnaires. CONCLUSIONS: The implementation of a structured educational workshop on perineal wound assessment and repair improves the confidence, skills and knowledge of midwives and students.

Proactive prevention: Act now to disrupt the impending non-communicable disease crisis in low-burden populations.

Non-communicable disease (NCD) prevention efforts have traditionally targeted high-risk and high-burden populations. We propose an alteration in prevention efforts to also include emphasis and focus on low-risk populations, predominantly younger individuals and low-prevalence populations. We refer to this approach as "proactive prevention." This emphasis is based on the priority to put in place policies, programs, and infrastructure that can disrupt the epidemiological transition to develop NCDs among these groups, thereby averting future NCD crises. Proactive prevention strategies can be classified, and their implementation prioritized, based on a 2-dimensional assessment: impact and feasibility. Thus, potential interventions can be categorized into a 2-by-2 matrix: high impact/high feasibility, high impact/low feasibility, low impact/high feasibility, and low impact/low feasibility. We propose that high impact/high feasibility interventions are ready to be implemented (act), while high impact/low feasibility interventions require efforts to foster buy-in first. Low impact/high feasibility interventions need to be changed to improve their impact while low impact/low feasibility might be best re-designed in the context of limited resources. Using this framework, policy makers, public health experts, and other stakeholders can more effectively prioritize and leverage limited resources in an effort to slow or prevent the evolving global NCD crisis.

Development of a telehealth intervention to promote care-seeking among transgender women of color in Washington, DC.

BACKGROUND: Transgender women of color (TWC) are an underserved population who often experience high rates of HIV and barriers to care including stigma, violence, and trauma. Few health information technology interventions are tailored to serve TWC. The purpose of this study was to inform the development of a TWC-specific telehealth intervention to increase access to care. METHODS: Formative qualitative semi-structured interviews and focus groups were conducted to develop a customized telehealth intervention for TWC. Participants were TWC ≥ 18 years living in the Washington, DC metropolitan area, with at least one structural barrier to care and clinicians ≥18 years who provide care to TWC. Transcripts were analyzed using thematic coding and content analysis; barriers for TWC were categorized into Individual, Organizational, and Environmental levels. Several day-long meetings with TWC and stakeholders were convened to develop the intervention. RESULTS: Saturation of theme on barriers to care was reached with 22 interviews. Identified barriers to service receipt included survival, instability, temporal discounting, and prioritizing hormone therapy over care, incongruence between providers and patients, pessimism, and lack of cultural competency. Each was intentionally addressed with the telehealth intervention. CONCLUSIONS: Data informed the development of an innovative and customized telehealth intervention for TWC. Through the integration of technology and peer consultant outreach, we developed a novel approach that can address population-specific challenges to care. Further development of this model may be able to improve health outcomes among TWC.

Try-It-On: Preparing family nurse practitioners to use holistic integrative interventions to reduce opioid prescriptions in chronic pain management.

In the United States, more than 130 people die each day from an opioid overdose. Nonopioid chronic pain management options are necessary in primary care. This educational innovation describes a new curriculum to teach future family nurse practitioner (FNP) prescribers holistic integrative interventions to decrease overprescribing of opioids for chronic pain management. The Modeling and Role Modeling theory and Kirkpatrick Evaluation Model guided the development and implementation of the curriculum innovation using a Try-It-On teaching-learning strategy, which focuses on immersion experience. The focus was to teach students to communicate effectively with patients in an effort to increase patient awareness of the pathophysiology of pain, risks of opioid use, and holistic integrative pain management options. Students learned to manage chronic pain within a holistic focus through immersion within integrative modalities, such as yoga, meditation, mindfulness, and guided imagery. Pre and post participation evaluations documented students' increased comfort level managing patients with chronic pain. Students reported they were much more likely to prescribe holistic integrative modalities after completing the Try-It-On learning modules. Holistic integrative interventions are a viable treatment option and/or adjunct treatment for chronic pain management. In conclusion, using the Try-It-On, teaching-learning strategy provided FNP students with the tools needed to prescribe nonopioid holistic integrative interventions to manage chronic pain.

Reliable sideline ocular-motor assessment following exercise in healthy student athletes.

OBJECTIVES: To assess the reliability and effect of exercise on sideline dynamic visual performance measures of ocular-motor function using a portable visual assessment system (EYE-SYNC®). DESIGN: Prospective cohort study. METHODS: Healthy student athletes, ages 18-25 years, performed eye-tracking six times-three times consecutively prior to and after practice-using EYE-SYNC® goggles. Ocular-motor performance was assessed by calculating five gaze error outcomes between target position and actual gaze position to inform dynamic visual synchronization. We assessed reliability by calculating the intraclass correlation coefficient (ICC) for each outcome (we defined the standard deviation of tangential error (SDTE) as our primary outcome) and calculated differences in mean pre- and post-practice scores. RESULTS: ICCs for the SDTE score were 0.86 (95% confidence interval, CI: 0.82-0.9) and 0.88 (0.84-0.91) at pre- and post-practice, respectively. 133 (89%) and 135 (90%) of 150 athletes had at least one measurement at pre- and post-practice, respectively. 117 (78%) and 122 (81%) athletes had more than one SDTE score at pre- and post-practice, respectively. The absolute mean (SD) differences between pre- and post-practice mean scores ranged from 0.02 (0.05) for horizontal gain to 0.1 (0.5) for SDTE. CONCLUSIONS: We observed high ICC scores indicating excellent reliability of visual synchronization measurements, suggesting that one measurement would be sufficient. Most athletes had similar scores before and after practice, indicating little change in visual performance following exercise. EYE-SYNC® goggles have the potential for use in obtaining objective visual performance measures of ocular-motor function for sideline assessment of concussion and return to play decisions.

PEMNetwork: Barriers and Enablers to Collaboration and Multimedia Education in the Digital Age.

In January 2005, PEMFellows.com was created to unify fellows in pediatric emergency medicine. Since then, the website has expanded, contracted, and focused to adapt to the interests of the pediatric emergency medicine practitioner during the internet boom. This review details the innovation of the PEMNetwork, from the inception of the initial website and its evolution into a needs-based, user-directed educational hub. Barriers and enablers to success are detailed with unique examples from descriptive analysis and metrics of PEMNetwork web traffic as well as examples from other online medical communities and digital education websites.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Aboriginal and Torres Strait Islander women's experiences accessing standard hospital care for birth in South Australia - A phenomenological study.

BACKGROUND: Aboriginal and Torres Strait Islander women, hereafter called Indigenous women, can experience a lack of understanding of their cultural needs when accessing maternity care in the standard hospital care system. AIM: To explore the lived experiences described by Indigenous women accessing labour and birth care in the standard hospital care system at a tertiary public hospital in South Australia. METHODS: An interpretive Heideggerian phenomenological approach was used. Indigenous women who accessed standard care voluntarily agreed to participate in semi-structured interviews with Indigenous interviewers. The interviews were transcribed and analysed informed by van Manen's approach. FINDINGS: Thematic analysis revealed six main themes: "knowing what is best and wanting the best for my baby", "communicating my way", "how they made me feel", "all of my physical needs were met", "we have resilience and strength despite our hardships" and "recognising my culture". CONCLUSION: Indigenous women in this study expressed and shared some of their cultural needs, identifying culturally unsafe practices. Recommendations to address these include the extension of current care planners to include cultural needs; Aboriginal Maternal Infant Care (AMIC) workers for women from rural and remote areas; AMIC workers on call to assist the women and midwives; increased education, employment and retention of Indigenous midwives; increased review into the women's experiences; removal of signs on the door restricting visitors in the birth suite; flexibility in the application of hospital rules and regulations; and changes to birthing services in rural and remote areas so women may not have to relocate for birth.

Cultural safety and midwifery care for Aboriginal women - A phenomenological study.

BACKGROUND: Aboriginal and Torres Strait islander(1) women face considerable health disparity in relation to their maternity health outcomes when compared to non-Aboriginal women. Culture and culturally appropriate care can contribute to positive health outcomes for Aboriginal women. How midwives provide culturally appropriate care and how the care is experienced by the women is central to this study. AIM: To explore the lived experiences of midwives providing care in the standard hospital care system to Aboriginal women at a large tertiary teaching hospital. METHODS: An interpretive Heideggerian phenomenological approach was used. Semi-structured interviews were conducted with thirteen volunteer midwives which were transcribed, analysed and presented informed by van Manen's approach. FINDINGS: Thematic analysis revealed six main themes: "Finding ways to connect with the women", "building support networks - supporting with and through Aboriginal cultural knowledge", "managing the perceived barriers to effective care", "perceived equity is treating women the same", "understanding culture" and "assessing cultural needs - urban versus rural/remote Aboriginal cultural needs". CONCLUSION: The midwives in this study have shared their stories of caring for Aboriginal women. They have identified communication and building support with Aboriginal health workers and families as important. They have identified perceived barriers to the provision of care, and misunderstanding around the interpretation of cultural safety in practice was found. Suggestions are made to support midwives in their practice and improve the experiences for Aboriginal women.

Evidence-based assessment of severe pediatric traumatic brain injury and emergent neurocritical care.

Pediatric traumatic brain injury accounts for approximately 474,000 emergency department visits, 37,000 hospitalizations, and 3,000 deaths in children 14 years and younger annually in the United States. Acute neurocritical care in children has advanced with specialized pediatric trauma centers and emergency medical services. This article reviews pediatric-specific diagnosis, management, and medical decision making related to the neurocritical care of severe traumatic brain injury.

The relationship between symptoms of depression and body weight in younger adults.

A bidirectional relationship between obesity and depression may exist, though previous results are conflicting. The objectives of our study were to determine whether there is a bidirectional relationship between obesity and symptoms of depression in younger adults and whether this relationship varies with sociodemographic factors. We used data from 7,980 participants in the National Longitudinal Survey of Youth 1979 to examine whether baseline depressive symptoms (score ≥ 10 on a seven-item subscale of the CES-D) in 1992, predicted adjusted percent change in BMI between 1992 and 1994. We then examined whether obesity in 1992 predicted the development of symptoms of depression in 1994, after adjustment for confounders. We found that the presence of baseline depressive symptoms was not prospectively associated with increase in percent BMI, except in Hispanic women. Additionally, baseline obesity was not associated with higher risk of future symptoms of depression in the sample overall (adjusted risk ratio (RR) 1.20; 99% CI 0.91-1.60). However, in those of higher socioeconomic status, obesity was associated with almost double the risk of depressive symptoms compared to nonobese (highest income category: adjusted RR 1.97; 99% CI 1.14-3.40). We concluded that although obesity was not associated with risk of depression symptoms in the population overall, obesity was associated with an increased risk of developing depressive symptoms in those of higher socioeconomic status. Sociodemographic factors may be important modifiers of the relationship between obesity and depression.

Obesity, race, and risk for death or functional decline among Medicare beneficiaries: a cohort study.

BACKGROUND: The adverse effect of obesity on health outcomes may be lower in older and African American adults than in the general U.S. population. OBJECTIVE: To examine and compare the relationship between obesity and all-cause mortality and functional decline among older U.S. adults. DESIGN: Longitudinal cohort study. SETTING: Secondary analysis of data from the 1994 to 2000 Medicare Current Beneficiary Surveys, linked to Medicare enrollment files through 22 April 2008. PARTICIPANTS: 20,975 community-dwelling participants in the 1994 to 2000 Medicare Current Beneficiary Surveys who were aged 65 years or older. MEASUREMENTS: All-cause mortality through 22 April 2008; new or worsening disability in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) in 2 years. RESULTS: 37% of the study sample were overweight (body mass index [BMI] of 25 to <30 kg/m(2)), 18% were obese (BMI ≥30 kg/m(2)), 48% died during the 14-year follow-up, and 27% had ADL and 43% had IADL disability at baseline. Among those without severe disability at baseline, 17% developed new or worsening ADL disability and 26% developed new or worsening IADL disability within 2 years. After adjustment, adults with a BMI of 35 kg/m(2) or greater were the only group above the normal BMI range who had a higher risk for mortality (hazard ratio, 1.49 [95% CI, 1.20 to 1.85] in men and 1.21 [CI, 1.06 to 1.39] in women, compared with the reference group [BMI of 22.0 to 24.9 kg/m(2)]; P for BMI-sex interaction = 0.003). In contrast, both overweight and obesity were associated with new or progressive ADL and IADL disability in a dose-dependent manner, particularly for white men and women. Significant interactions were detected between BMI and sex but not between BMI and race for any outcome, although risk estimates for ADL disability seemed attenuated in African American relative to white respondents. LIMITATION: This was an observational study, baseline data were self-reported, and the study had limited power to detect differences between white and African American respondents. CONCLUSION: Among older U.S. adults, obesity was not associated with mortality, except for those with at least moderately severe obesity. However, lower levels of obesity were associated with new or worsening disability within 2 years. Efforts to prevent disability in older adults should target those who are overweight or obese. PRIMARY FUNDING SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases.

Effect of membrane microheterogeneity and domain size on fluorescence resonance energy transfer.

Studies of multicomponent membranes suggest lateral inhomogeneity in the form of membrane domains, but the size of small (nanoscale) domains in situ cannot be determined with current techniques. In this article, we present a model that enables extraction of membrane domain size from time-resolved fluorescence resonance energy transfer (FRET) data. We expand upon a classic approach to the infinite phase separation limit and formulate a model that accounts for the presence of disklike domains of finite dimensions within a two-dimensional infinite planar bilayer. The model was tested against off-lattice Monte Carlo calculations of a model membrane in the liquid-disordered (l(d)) and liquid-ordered (l(o)) coexistence regime. Simulated domain size was varied from 5 to 50 nm, and two fluorophores, preferentially partitioning into opposite phases, were randomly mixed to obtain the simulated time-resolved FRET data. The Monte Carlo data show clear differences in the efficiency of energy transfer as a function of domain size. The model fit of the data yielded good agreement for the domain size, especially in cases where the domain diameter is <20 nm. Thus, data analysis using the proposed model enables measurement of nanoscale membrane domains using time-resolved FRET.

Risk of cardiovascular events and death--does insurance matter?

BACKGROUND: Many Americans lack health insurance. Despite good evidence that lack of insurance compromises access to care, few prospective studies examine its relationship to health outcomes. OBJECTIVE: To determine the relationship between insurance and cardiovascular outcomes and the relationship between insurance and selected process measures. DESIGN AND PARTICIPANTS: We used data from 15,792 participants in the Atherosclerosis Risk in Communities Study, a prospective cohort study. Participants were enrolled in 1987-1989 and returned for follow-up visits every 3 years, for a total of 4 visits. MAIN OUTCOME MEASURES: We estimated the hazard of myocardial infarction, stroke, and death associated with insurance status using Cox proportional hazard modeling. We used generalized estimating equations to examine the association between insurance status and risk of (1) reporting no routine physical examinations, (2) being unaware of a personal cardiovascular risk condition, and (3) inadequate control of cardiovascular risk conditions. RESULTS: Persons without insurance had higher rates of stroke (adjusted hazard ratio, 95% CI 1.22-2.22) and death (adjusted hazard ratio 1.26, 95% CI 1.03-1.53), but not myocardial infarction, than those who were insured. The uninsured were less likely to report routine physical examinations (adjusted risk ratio 1.13, 95% CI 1.08-1.18); more likely to be unaware of hypertension (adjusted risk ratio 1.12, 95% CI 1.00-1.25) and hyperlipidemia (adjusted risk ratio 1.11, 95% CI 1.03-1.19); and more likely to have poor blood pressure control (adjusted risk ratio 1.23, 95% CI 1.08-1.39). CONCLUSIONS: Lack of health insurance is associated with increased rates of stroke and death and with less awareness and control of cardiovascular risk conditions. Health insurance may improve cardiovascular risk factor awareness, control and outcomes.

Differences in access to outpatient medical care for black and white adults in the rural South.

OBJECTIVES: We compared black and white adults in the rural South on multiple indicators of access to outpatient medical care and assessed whether any differences might be explained by group differences in socioeconomic situations or proximity to medical resources. DESIGN: Cross-sectional telephone survey. SUBJECTS: Survey respondents were 1237 black and 2158 white adults from 113 rural counties in 6 southern states. MEASURES: Blacks and whites were compared on a variety of commonly used survey measures of access, some followed in the Healthy People 2010 Initiative. Access comparisons were adjusted for age, gender, and health status and then reassessed with adjustments for individual socioeconomic indicators and county medical resources: physician-to-population ratios, the presence of hospitals and federally qualified health centers, and urban adjacency. RESULTS: Compared with whites, blacks reported similar or higher use of outpatient services over the previous year, including the likelihood of having had an outpatient physician visit and regular checkup. Nevertheless, blacks more often reported forgoing needed care, encountering various barriers, and experiencing dissatisfaction with some aspects of care. Adjusting for socioeconomic factors generally reduced but did not eliminate black-white access differences, whereas adjusting for county medical care resources did not affect measured group differences. CONCLUSIONS: Blacks and whites in the rural South report similar use rates of outpatient medical care, but blacks more often report unmet needs, barriers to care, and dissatisfaction with care. Beyond socioeconomic differences, black versus white differences in sites of care, the quality of care received, the quality of interactions with providers, and expectations for their care may explain group reported access differences.

Perception of racial barriers to health care in the rural South.

We assessed how commonly people in the rural South perceive racial barriers to care, the characteristics of the people among whom this perception is most common and whether this perception is associated with satisfaction with and use of health services. We analyzed telephone survey data collected in 2002-3, using weighted statistical techniques and multivariate logistic regression in analyses stratified by race. Fifty-four percent of African Americans and 23% of Whites reported that they perceive racial barriers to care in their communities. African Americans who were middle-aged or older, male, or who report being in good-to-excellent health were more likely to perceive racial barriers. Whites who were younger, less educated, and uninsured were more likely than other Whites to perceive racial barriers. For African Americans, perceptions of racial barriers were associated with lower likelihood of being satisfied with care, but not with use of preventive services. The perception of racial barriers to health care is prevalent in the rural South, especially among African Americans. The consequences of this perception may include mistrust and dissatisfaction with medical care.

Exercise tolerance testing to screen for coronary heart disease: a systematic review for the technical support for the U.S. Preventive Services Task Force.

BACKGROUND: Coronary heart disease is the leading cause of morbidity and mortality in the United States. Exercise tolerance testing has been proposed as a means of better identifying asymptomatic patients at high risk for coronary heart disease events. PURPOSE: To review the evidence on the use of exercise tolerance testing to screen adults with no history of cardiovascular disease for coronary heart disease. DATA SOURCES: The MEDLINE database from 1966 through February 2003, hand-searching of bibliographies, and expert input. STUDY SELECTION: Eligible studies evaluated the benefits or harms of exercise tolerance testing when added to traditional risk assessment for adults with no known history of cardiovascular events. DATA EXTRACTION: One reviewer extracted information from eligible articles into evidence tables, and another reviewer checked the tables. Disagreements were resolved by consensus. DATA SYNTHESIS: No study has directly examined the effect of screening asymptomatic patients with exercise tolerance testing on coronary heart disease outcomes or risk-reducing behaviors or therapies. Multiple cohort studies demonstrate that screening exercise tolerance testing identifies a small proportion of asymptomatic persons (up to 2.7% of those screened) with severe coronary artery obstruction who may benefit from revascularization. Several large prospective cohort studies, conducted principally in middle-aged men, suggest that exercise tolerance testing can provide independent prognostic information about the risk for future coronary heart disease events (relative risk with abnormal exercise tolerance testing, 2.0 to 5.0). However, when the risk for coronary heart disease events is low, most positive findings will be false and may result in unnecessary further testing or worry. The risk level at which the benefits of additional prognostic information outweigh the harms of false-positive results is unclear and requires further study. CONCLUSIONS: Although screening exercise tolerance testing detects severe coronary artery obstruction in a small proportion of persons screened and can provide independent prognostic information about the risk for coronary heart disease events, the effect of this information on clinical management and disease outcomes in asymptomatic patients is unclear.