Five Dimensions of Needs for Help: The Efficacy of a Technology-Based Intervention Among Asian American Breast Cancer Survivors.

Cancer survivors including Asian American breast cancer survivors have reported their high needs for help during their survivorship process. With the COVID-19 pandemic, the necessity of technology-based programs to address their needs for help without face-to-face interactions has been highlighted. The purpose of this randomized intervention study was to determine the efficacy of a technology-based program in reducing various types of needs for help among this specific population. This was a randomized clinical trial with repeated measures. A total of 199 participants were included in the data analysis. The recruitment settings included both online and offline communities/groups for Asian Americans. The needs for help were assessed using the Support Care Needs Survey-34 Short Form (SCNS) subscales measuring psychological, information, physical, support, and communication needs. Data analysis was conducted through an intent-to-treat approach. In the mixed effect models, psychological needs, information needs, physical needs, and communication needs decreased over time (P < .001). However, there were no significant group * time effects. Social support significantly mediated the effects of a technology-based intervention on psychological, information, and support needs at the pre-test and the post-1 month. This study supported significant decreases in the needs for help of Asian American breast cancer survivors by a technology-based intervention. Further studies are needed with other racial/ethnic groups of cancer survivors to confirm the efficacy of a technology-based intervention in reducing cancer survivors' needs for help during their survivorship process.

The value of nurse bioethicists.

BACKGROUND: The field of nursing has long been concerned with ethical issues. The history of the nursing profession has a rich legacy of attention to social justice and to societal questions regarding issues of fairness, access, equity, and equality. Some nurses have found that their clinical experiences spur an interest in ethical patient care, and many are now nurse bioethicists, having pursued additional training in bioethics and related fields (e.g., psychology, sociology). PURPOSE: The authors describe how the clinical and research experiences of nurses give them a unique voice in the field of bioethics. RESULTS: Authors present reasons for the relative invisibility of nurse bioethicists, compared with physician, theologian, or philosopher bioethicists, as well as current efforts to increase the visibility of nurse bioethicists. They also describe four specific areas where nurse bioethicists have made and continue to make important contributions: as ethics consultants to colleagues in hospitals and other settings; as bioethics researchers or as advisers to researchers conducting trials with human subjects; as educators of trainees, patients and families, healthcare providers, and the public; and in helping to draft humane and ethical policies for the care of vulnerable patients and underserved populations. CONCLUSION: Nurse bioethicists are central to the future goals of healthcare bringing a unique perspective to the day-to-day ethical challenges of both clinical care and research, as well as to the education of health professionals and the public.

Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation.

BACKGROUND: Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE: To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS: This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS: In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS: Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.

Injured black men's perceptions of the recovery environment.

BACKGROUND: Black men are disproportionately impacted by injuries in the United States. This disparity is glaring given that injury is one of the top ten causes of death. Injured Black men from disadvantaged neighborhoods experience higher injury mortality, years of life-expectancy loss, and psychological symptoms that persist after initial wounds have been treated. These injured men are typically transported to a hospital where they are medically stabilized and soon after are returned to the community. Black men are less likely to be discharged to comprehensive rehabilitation facilities, magnifying disparities in recovery from injury. While much research has examined individual characteristics that predict poor recovery from injury, fewer studies have focused on social and physical features of the environment and how they may impact the recovery of injury survivors. PURPOSE: The purpose of this study was to describe Black men's perceptions of how characteristics of their environment affect their recovery following serious injury. METHODS: This was a secondary analysis of an existing data set consisting of semi-structured, qualitative interviews of 43 injured Black men in a northeastern city. The interviews were conducted three months following discharge from a large urban trauma center, and were audiotaped, transcribed verbatim, and de-identified. Thematic analysis consistent with the qualitative paradigm was used to identify themes. RESULTS: Four themes were identified in injured men's narratives: challenges to recovery, feeling unsafe, efforts to increase safety, and resources for recovery. CONCLUSIONS: Our findings emphasize the importance of the role of community resources that can support injured men's recovery within their neighborhoods. Additional resources should be directed to survivors who return to disadvantaged communities after injury in order to minimize adverse emotional experiences that detract from recovery.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

The ethics of sensor technology use in clinical research.

Sensor-based technologies are used today in clinical practice, research, and for monitoring people's health in homes across the United States. Although the increasing growth and complexity of such technologies promises both direct and indirect benefits, significant ethical concerns are raised. We discuss several of these concerns, particularly those that arise in clinical research and outline ethical considerations that pertain to the concept of informed consent, participants' understanding of risks and benefits and the need for tailored and accessible information that will enable participants to fully understand research implications. Balancing the benefits with the potential risks of advanced information technology will require ethically astute researchers who can address the challenges that might arise while advancing knowledge with innovation that can improve the lives of patients and families.

Goals-of-Care Consultation Associated With Increased Hospice Enrollment Among Propensity-Matched Cohorts of Seriously Ill African American and White Patients.

CONTEXT: African Americans are less likely to receive hospice care and more likely to receive aggressive end-of-life care than whites. Little is known about how palliative care consultation (PCC) to discuss goals of care is associated with hospice enrollment by race. OBJECTIVES: To compare enrollment in hospice at discharge between propensity-matched cohorts of African Americans with and without PCC and whites with and without PCC. METHODS: Secondary analysis of a retrospective cohort study at a high-acuity hospital; using stratified propensity-score matching for 35,154 African Americans and whites aged 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at end of study, and did not die during index hospitalization (hospitalization during which first PCC occurred). RESULTS: Compared with African Americans without PCC, African Americans with PCC were 15 times more likely to be discharged to hospice from index hospitalization (2.4% vs. 36.5%; P < 0.0001). Compared with white patients without PCC, white patients with PCC were 14 times more likely to be discharged to hospice from index hospitalization (3.0% vs. 42.7%; P < 0.0001). CONCLUSION: In propensity-matched cohorts of seriously ill patients, PCC to discuss goals of care was associated with significant increases in hospice enrollment at discharge among both African Americans and whites. Research is needed to understand how PCC influences decision making by race, how PCC is associated with postdischarge hospice outcomes such as disenrollment and hospice lengths of stay, and if PCC is associated with improving racial disparities in end-of-life care.

Covid-19: Ethical Challenges for Nurses.

The Covid-19 pandemic has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. The decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. Our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. This essay discusses three overarching ethical issues that create a myriad of concerns and will likely affect nurses globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses' relationships with patients and families. We urge policy-makers to ensure that nurses' voices and perspectives are integrated into both local and global decision-making so as to minimize the structural injustices many nurses have faced to date. Finally, we urge nurses to seek sources of support throughout this pandemic.

Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness.

Background: African Americans receive more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care ("PCC") is associated with acute care utilization and costs by race. Objective: To compare future acute care costs and utilization between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC. Design: Secondary analysis of a retrospective cohort study. Setting/Subjects: Thirty-five thousand one hundred and fifty-four African Americans and Whites age 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at the end of the study, and did not die during index hospitalization (hospitalization during which the first PCC occurred). Measurements: Accumulated mean acute care costs and utilization (30-day readmissions, future hospital days, future intensive care unit [ICU] admission, future number of ICU days) after discharge from index hospitalization. Results: No significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, p = 0.09), 30-day readmissions (p = 0.58), future hospital days (p = 0.34), future ICU admission (p = 0.25), or future ICU days (p = 0.30). There were significant differences between Whites with PCC and those without PCC in mean future acute care costs ($8,095 vs. $16,799, p < 0.001), 30-day readmissions (10.2% vs. 16.7%, p < 0.0001), and future days hospitalized (3.7 vs. 6.3 days, p < 0.0001). Conclusions: PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans. Research is needed to explain why utilization and cost disparities persist among African Americans despite PCC.

Acceptability of financial incentives for health-related behavior change: An updated systematic review.

Despite the successes of financial incentives in increasing uptake of evidence-based interventions, acceptability is polarized. Given widespread interest in the use of financial incentives, we update findings from Giles and colleagues' 2015 systematic review (n = 81). The objectives of this systematic review are to identify what is known about financial incentives directed to patients for health-related behavior change, assess how acceptability varies, and address which aspects and features of financial incentives are potentially acceptable and not acceptable, and why. PRISMA guidelines were used for searching peer-reviewed journals across 10 electronic databases. We included empirical and non-empirical papers published between 1/1/14 and 6/1/18. After removal of duplicates, abstract screening, and full-text reviews, 47 papers (n = 31 empirical, n = 16 scholarly) met inclusion criteria. We assessed empirical papers for risk of bias and conducted a content analysis of extracted data to synthesize key findings. Five themes related to acceptability emerged from the data: fairness, messaging, character, liberty, and tradeoffs. The wide range of stakeholders generally preferred rewards over penalties, vouchers over cash, smaller values over large, and certain rewards over lotteries. Deposits were viewed unfavorably. Findings were mixed on acceptability of targeting specific populations. Breastfeeding, medication adherence, smoking cessation, and vaccination presented as more complicated incentive targets than physical activity, weight loss, and self-management. As researchers, clinicians, and policymakers explore the use of financial incentives for challenging health behaviors, additional research is needed to understand how acceptability influences uptake and ultimately health outcomes.

Associations Among End-of-Life Discussions, Health-Care Utilization, and Costs in Persons With Advanced Cancer: A Systematic Review.

BACKGROUND: Aggressive end-of-life (EOL) care is associated with lower quality of life and greater regret about treatment decisions. Higher EOL costs are also associated with lower quality EOL care. Advance care planning and goals-of-care conversations ("EOL discussions") may influence EOL health-care utilization and costs among persons with cancer. OBJECTIVE: To describe associations among EOL discussions, health-care utilization and place of death, and costs in persons with advanced cancer and explore variation in study measures. METHODS: A systematic review was conducted using PubMed, Embase, and CINAHL. Twenty quantitative studies published between January 2012 and January 2019 were included. RESULTS: End-of-life discussions are associated with lower health-care costs in the last 30 days of life (median US$1048 vs US$23482; P < .001); lower likelihood of acute care at EOL (odds ratio [(OR] ranging 0.43-0.69); lower likelihood of intensive care at EOL (ORs ranging 0.26-0.68); lower odds of chemotherapy near death (ORs 0.41, 0.57); lower odds of emergency department use and shorter length of hospital stay; greater use of hospice (ORs ranging 1.79 to 6.88); and greater likelihood of death outside the hospital. Earlier EOL discussions (30+ days before death) are more strongly associated with less aggressive care outcomes than conversations occurring near death. CONCLUSIONS: End-of-life discussions are associated with less aggressive, less costly EOL care. Clinicians should initiate these discussions with patients having cancer earlier to better align care with preferences.

Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries.

IMPORTANCE: Differences in utilization and costs of end-of-life care among developed countries are of considerable policy interest. OBJECTIVE: To compare site of death, health care utilization, and hospital expenditures in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using administrative and registry data from 2010. Participants were decedents older than 65 years who died with cancer. Secondary analyses included decedents of any age, decedents older than 65 years with lung cancer, and decedents older than 65 years in the United States and Germany from 2012. MAIN OUTCOMES AND MEASURES: Deaths in acute care hospitals, 3 inpatient measures (hospitalizations in acute care hospitals, admissions to intensive care units, and emergency department visits), 1 outpatient measure (chemotherapy episodes), and hospital expenditures paid by insurers (commercial or governmental) during the 180-day and 30-day periods before death. Expenditures were derived from country-specific methods for costing inpatient services. RESULTS: The United States (cohort of decedents aged >65 years, N = 211,816) and the Netherlands (N = 7216) had the lowest proportion of decedents die in acute care hospitals (22.2.% and 29.4%, respectively). A higher proportion of decedents died in acute care hospitals in Belgium (N = 21,054; 51.2%), Canada (N = 20,818; 52.1%), England (N = 97,099; 41.7%), Germany (N = 24,434; 38.3%), and Norway (N = 6636; 44.7%). In the last 180 days of life, 40.3% of US decedents had an intensive care unit admission compared with less than 18% in other reporting nations. In the last 180 days of life, mean per capita hospital expenditures were higher in Canada (US $21,840), Norway (US $19,783), and the United States (US $18,500), intermediate in Germany (US $16,221) and Belgium (US $15,699), and lower in the Netherlands (US $10,936) and England (US $9342). Secondary analyses showed similar results. CONCLUSIONS AND RELEVANCE: Among patients older than 65 years who died with cancer in 7 developed countries in 2010, end-of-life care was more hospital-centric in Belgium, Canada, England, Germany, and Norway than in the Netherlands or the United States. Hospital expenditures near the end of life were higher in the United States, Norway, and Canada, intermediate in Germany and Belgium, and lower in the Netherlands and England. However, intensive care unit admissions were more than twice as common in the United States as in other countries.

Cancer clinical trial participants' assessment of risk and benefit.

BACKGROUND: The purpose of this article is to examine the extent to which cancer clinical trial participants assess the benefits and risks of research participation before enrollment. METHODS: One hundred and ten oncology research participants enrolled in cancer clinical research in a large Northeastern cancer center responded to a self-administered questionnaire on perceptions about cancer clinical trials. RESULTS: Of the participants, 51.6% reported they did not directly assess the benefits or risks. Educational level, age, employment, treatment options, insurance, and spiritual-religious beliefs were significantly associated with whether participants assessed risk and benefits. Those who felt well informed were more likely to have assessed the benefits and risks at enrollment than those who did not feel well informed (odds ratio [OR] = 3.92, p = .014); of those who did not assess the risks and benefits, 21% did not feel well informed at enrollment (p = .001). Those who agreed that the clinical trial helped pay the costs of the care had nearly three times the odds of not assessing risks and benefits compared to those who disagreed. CONCLUSION: Our findings have important implications for understanding the role of assessing risks and benefits in the research participation decisions of patients with cancer and call for further understanding of why participants are not assessing information believed to be essential for autonomous informed decisions.

Predictors of ethical stress, moral action and job satisfaction in health care social workers.

Value conflicts can be a source of ethical stress for social workers in health care settings. That stress, unless mediated by the availability of ethical resource services, can lead to social workers' dissatisfaction with their positions and careers, and possibly result in needed professionals leaving the field. This study explored social workers' experiences in dealing with ethical issues in health care settings. Findings showed the inter-relationship between selected individual and organizational factors and overall ethical stress, the ability to take moral actions, the impact of ethical stress on job satisfaction, and the intent to leave position.

Ethical conflict in nurse practitioners and physician assistants in managed care.

BACKGROUND: More patients are receiving healthcare services from nurse practitioners (NPs) and physician assistants (PAs). These providers are likely to be confronted with a variety of ethical issues as they balance quality care with their patients' rising cost concerns. However, very little is known about the ethical conflicts and causes of these conflicts experienced by these clinicians in their daily practice. OBJECTIVE: To identify ethical concerns and conflicts NPs and PAs encounter related to managed care in the delivery of primary care to patients and the factors that influence ethical conflict. METHODS: A cross-sectional self-administered mailed questionnaire was sent to 3,900 NPs and PAs randomly selected from primary care and primary care subspecialties in the United States (adjusted response rate, 50.6%). Respondents were surveyed on ethical issues and concerns, ethics preparedness, and ethical conflict. Bivariate and multiple linear regression analyses were used to evaluate predictors of ethical conflict. RESULTS: Insurance constraints were reported to have interfered with the ability to provide quality patient care by 72% of respondents, with 55.3% reporting daily to weekly interferences. Nearly half of respondents (47%) have been asked by a patient to mislead insurers to assist them in receiving care. A perceived obligation to advocate for patients, even if it means exaggerating the severity of a patient's condition, was the single most significant predictor of ethical conflict, explaining 25% of the variance. DISCUSSION: NPs and PAs are experiencing ethical conflict often associated with their perceived professional obligations to advocate for patients. Being well-prepared in ethics and having sufficient professional independence help clinicians balance the ethical complexities and demands of meeting patients' needs within a constrained healthcare system.

A path analytic model of ethical conflict in practice and autonomy in a sample of nurse practitioners.

The purpose of this study was to test a causal model of ethical conflict in practice and autonomy in a sample of 254 nurse practitioners working in the primary care areas of family health, pediatrics, adult health and obstetrics/gynecology in the state of Maryland. A test of the model was conducted using a path analytic approach with LISREL 8.30 hypothesizing individual, organizational and societal/market factors influencing ethical conflict in practice and autonomy. Maximum likelihood estimation was used to estimate the parameters most likely to have generated the data. Forty-five percent of the total variance in ethical conflict was explained by the variables of ethical environment and ethical concern. Ethical concern, idealistic philosophy, ethics education in continuing education, percentage of client population enrolled in managed care, and market penetration explained 15% of the total variance in autonomy. The findings of this study indicate that the causal model of ethical conflict in practice and autonomy is consistent with the data and contributed to a fuller understanding of clinical decision making associated with practicing in a managed care environment. The final model supported a conceptual framework that is inclusive of three domains: individual, organizational and societal/market variables.

Does it pay to pay? A randomized trial of prepaid financial incentives and lottery incentives in surveys of nonphysician healthcare professionals.

BACKGROUND: Monetary incentives in survey research may provide important gains from a methodological perspective in the control and reduction of survey error associated with potential nonresponse of participants. However, few studies have systematically investigated the use of monetary incentives or other methods to improve the response rates in the nonphysician clinician population. OBJECTIVE: To investigate differences in response rates to a mailed self-administered survey of nonphysician clinicians who were randomized to receive a prepaid monetary incentive, a postsurvey prize drawing, or no incentive. METHODS: A randomized controlled trial of financial incentives was conducted from November 2002 to February 2003. Nonphysician clinicians (nurse practitioners [NPs] and physician assistants [PAs]; N = 3,900) randomly selected to participate in a national ethics-related study were assigned randomly in equal allocations (n = 1,300 [650 NPs, 650 PAs]) to three incentive groups: (a) no incentive; (b) a $5 prepaid token incentive in the initial mailing; or (c) a chance to win one of ten $100 prize drawings upon completion and return of a self-administered survey. RESULTS: A $5 cash incentive increased survey response rates to an adjusted 64.2%: a 19.5 percentage point increase over the lottery group (44.7% response rate), and a 22 percentage point increase over the control group (42.2% response rate). DISCUSSION: A nominal cash incentive of $5 yields a significantly higher response rate from nonphysician providers than receiving either a lottery option or no incentive.

Ethical conflict associated with managed care: views of nurse practitioners.

BACKGROUND: Ethical conflict of nurse practitioners (NPs) practicing within a managed care environment has not been systematically examined, yet like physician practitioners, NPs are confronted with daily ethical conflicts. OBJECTIVE: To determine perceptions toward ethical conflict in practice espoused by NPs affiliated with managed care systems and to identify the relationship between selected individual, organizational, and societal/market contextual factors and ethical conflict in practice. METHOD: Descriptive, cross-sectional, correlational survey of a stratified random sample of 700 NPs licensed and certified to practice in the state of Maryland, conducted from November 2000 to January 2001. RESULTS: A majority of respondents reported being moderately to extremely concerned with managed care. Eighty percent of the sample perceived that it was sometimes necessary to bend managed care guidelines with 61% agreeing that the practitioner must weigh the patient's interest against managed care organizations' interests. The NPs in a staff/group model health maintenance organization (a) were less ethically concerned (p <.001); (b) perceived the ethical environment more positively (p <.001); and (c) had lower ethical conflict scores (p <.001) than NPs in other types of practice settings. DISCUSSION: Results from this study indicate that NPs are experiencing ethical conflict associated with practicing within a managed care environment; however, NPs in a staff/group model health maintenance organization report these concerns less. Ethical support through intervening strategies (i.e., ethics education and interdisciplinary ethics support systems) may help mitigate the conflict associated with this system of care.