School Nurses' Experiences of Organizational Support During the COVID-19 Pandemic.

School nurses encountered many workplace struggles while providing care during the COVID-19 pandemic. Several struggles involved organizational support, including having sufficient time, resources, compensation, and school leadership support. The purpose of this mixed methods study was to explore the experiences of school nurses working during the COVID-19 pandemic as they related to sufficient time to complete COVID-related activities, sufficient COVID-19 resources, compensation, and perceived organizational (school leadership) support. We obtained data from 1,564 National Association of School Nurses members regarding respondent characteristics, school characteristics, measures of organizational support, and qualitative perceived organizational support using a 17-question survey. Perceptions of having sufficient time to complete COVID-related tasks and infringement of these tasks on routine activities were worse for those with greater years of experience and education. Compensation for additional COVID-related work was more favorable for LPNs. School leaders should be aware of their role in bolstering organizational support and its impact.

Certified Registered Nurse Anesthetists' occupational exposure to inhalational anesthetic agents: a survey of anesthetic gas safety.

BACKGROUND: Anesthetic gases have been known to cause damage when inhaled over long periods of time. Modern safety measures have been put in place to reduce the risk to anesthesia providers, however there is continued lack of information on providers experiencing short term effects (lethargy, fatigue, headache, slowed cognitive ability, nausea, and mucosal irritation) thereby leading to long-term sequalae (sister chromatid exchanges, micronuclei, chromosomal aberrations, and comet assays). METHOD: A thirteen item, multiple choice survey was sent to 3,000 anesthesia providers, of which 463 completed the survey. A Chi-square test of independence was used to determine the association between gas exposure and participant self-reported symptoms. A Spearman's Correlation test was also utilized to interpret this data since both frequency of smelling gas and frequency of symptoms were ordinal variables for which Spearman's rho correlation was the appropriate measure of association. RESULTS: The major findings were that as the frequency of smelling anesthetic gas increased, so too did the frequency of self-reported headaches and fatigue. Spearman's rho = .148 and .092. P value = .002 and .049, respectively. CONCLUSION: There have been many efforts to decrease the risk of exposure of anesthesia providers to anesthetic gases. While there is a decrease in reported exposures, indications of possible long-term effects remain a concern in anesthesia providers. Potential implications of exposure could lead to chromosomal aberrations, sister chromatid exchanges, comet assays, spontaneous abortions, and genotoxic effects.

Chronic Intravenous Inotropic Support as Palliative Therapy and Bridge Therapy for Patients With Advanced Heart Failure: A Single-Center Experience.

BACKGROUND: Many patients with American College of Cardiology/American Heart Association Stage D (advanced) heart failure are discharged home on chronic intravenous inotropic support (CIIS) as bridge to surgical therapy or as palliative therapy. This study analyzed the clinical trajectory of patients with advanced heart failure who were on home CIIS. METHODS: We conducted a single-institution, retrospective cohort study of patients on CIIS between 2010 and 2016 (n = 373), stratified by indication for initiation of inotropic support. Study outcomes were time from initiation of CIIS to cessation of therapy, time to death for patients who did not receive surgical therapy and rates of involvement with palliative care. RESULTS: Overall, patients received CIIS therapy for an average of 5.9 months (standard deviation [SD] 7.3). Patients on CIIS as palliative therapy died in an average of 6.2 months (SD 6.6) from the time of initiation of CIIS, and those on CIIS as bridge therapy who did not ultimately receive surgical therapy died after an average of 8.6 months (SD 9.3). Patients who received CIIS as bridge therapy were significantly less likely to receive palliative-care consultation than those on inotropes as palliative therapy, whether or not they underwent surgery. CONCLUSIONS: In this large cohort of patients with advanced HF, patients who on CIIS as palliative therapy survived for 6.2 months, on average, with wide variation among patients. Patients who were on CIIS as bridge therapy but did not ultimately receive surgical therapy received less palliative care despite the high mortality rate in this subgroup.

Mentoring students engaging in scholarly projects and dissertations in doctoral nursing programs.

BACKGROUND: Doctor of Nursing Practice (DNP) programs in the US have grown exponentially, outnumbering Doctor of Philosophy (PhD) in Nursing programs. Faculty are mentoring increasing numbers of students on DNP projects or PhD dissertations. PURPOSE: This descriptive study explored faculty characteristics and examined support, engagement, and outcomes of American Association of Colleges of Nursing member nursing faculty mentoring student DNP projects or PhD dissertations. METHOD: A researcher-developed survey tool was emailed to 550 Deans and Program Directors of AACN doctoral programs for distribution to their doctoral faculty. Survey data were analyzed using descriptive statistics. FINDINGS: 177 DNP and 53 PhD (N=230) program surveys were completed. Faculty described challenges in the mentoring role including: time constraints, workload allocation, resources, faculty role preparation, student readiness, and variability in student outcomes. CONCLUSIONS: Additional dialogue and consensus is required to promote mentoring of students in nursing doctoral programs to ensure rigor of scholarly outcomes.

Parental perceptions of congenital cardiovascular malformations in their children.

We assessed parental attitudes towards congenital cardiovascular malformations in their children in a cross-sectional study in Egypt. Parents face many problems related to concerns about their child's prognosis, but these associations with parental stress have never been evaluated in Egypt or examined in relation to religiosity in a predominantly Muslim society. Accordingly, we conducted interviews in Cairo with mothers of 99 sequential infants born with conotruncal heart malformations (cases) and 65 mothers of age-matched controls. The survey assessed healthcare access and usage, knowledge of congenital cardiovascular malformations, religiosity, the Locus of Control Scale, and the Parenting Stress Index. Results showed that 45% of the mothers of cases had correct knowledge about their child's diagnosis; 85% were satisfied with the clinical care; and 79% reported that the cost of care was burdensome. Compared with parents of cases, parents of controls were more likely to report stress overall and all its subscales. Regarding belief about locus of control over health, God as a determining factor was given the highest endorsement. Mothers in the congenital cardiovascular malformations group reported a higher level of parental locus of control than did those in the control group. The correlations between stress and locus of control were stronger in the control than in the case group. Religiosity was related neither to stress nor to locus of control. Future studies can explore the roles that personal, familial, and societal factors play in exacerbating or reducing stress levels among parents of sick children, particularly in developing countries where economic pressures are acute.

Impact of a mindfulness and self-care intervention on stress, self-compassion, and attentiveness in university healthcare students and faculty.

OBJECTIVE: To evaluate impact of a 12-week, online, guided, self-paced intervention of mindfulness and self-care practices on self-compassion, attentiveness, and perceived stress. PARTICIPANTS: University healthcare faculty and students. METHODS: Participants received 7 different mindful and self-care activity options every week for 12 wk. A pre-survey, weekly surveys, and one-month post-survey assessed outcome measures of the Perceived Stress Scale 4, Self-Compassion Scale-SF, Mindful Attention Awareness Scale, health behaviors, and feasibility. RESULTS: A total of 232 participants had one or more outcome measures and 68 completed all 14 measures. Students and faculty demonstrated significantly increased mindful attention awareness, days of mindfulness practice, self-compassion, and trended toward more physical activity. They reported significantly lower stress and that mindful practice altered the way they dealt with stress. Days of mindfulness practice were significantly negatively correlated to stress and positively correlated to self-care. CONCLUSIONS: This intervention demonstrated both effectiveness and feasibility, with most participants choosing shorter meditation, yoga, and self-care options.

Prognostic Implications of Delirium After Left Ventricular Assist Device Implantation: A Retrospective Study.

BACKGROUND: In critically ill patients, delirium is a prognostic indicator of morbidity and mortality. OBJECTIVE: This study investigates the impact of a delirium diagnosis on outcomes after left ventricular assist device (LVAD) implantation. METHODS: This retrospective study included all adult patients who received LVADs at our institution between January 2016 and December 2020. We compared preimplantation characteristics between the two groups, with and without a diagnosis of delirium, and compared their outcomes, including 1-month, 6-month, and in-hospital mortality, as well as reintubation rate, length of stay, discharge disposition, and readmission rates. RESULTS: In total, 361 patients (26.7% women and 75.8% African American) received durable LVADs. Ninety-four patients (26.1%) were diagnosed with delirium during the index admission. Preimplantation demographic characteristics, past medical and psychiatric conditions, Interagency Registry for Mechanically Assisted Circulatory Support Profile, and laboratory values did not differ between the two groups with and without a diagnosis of delirium; older age (59 vs 56; P = 0.03) was associated with delirium. Delirium diagnosis was associated with higher 1-month (P = 0.007), 6-month (P = 0.004), and in-hospital mortality (P < 0.001), unplanned reintubations (P < 0.001), and a lower likelihood of discharge home (P = 0.03). Total hospital and intensive care unit length of stay were higher in patients with a diagnosis of delirium, though these results were not statistically significant. Readmission to the hospital after index admission was quicker in patients with a diagnosis of delirium, but this result was not statistically significant. CONCLUSIONS: In this study, a diagnosis of delirium during the LVAD implantation admission was associated with higher mortality, adverse postsurgical outcomes, and unfavorable discharge dispositions. Future prospective research is needed to validate the prognostic implications of delirium in both the short and long term. Additionally, there is a need to identify modifiable risk factors associated with delirium to promote early diagnosis and implement evidence-based management strategies to enhance outcomes within this population.

Disease-State Understanding and Experience of Patients Receiving Continuous Intravenous Inotropic Support as Palliative Therapy: A Multicenter Survey.

Background: The use of continuous intravenous inotropic support (CIIS) as palliative therapy in patients with advanced heart failure (HF) has increased over the past decade. CIIS improves New York Heart Association (NYHA) functional class but does not impact survival. Objective: The objective of this study was to examine patients' understanding of the therapeutic intent of CIIS, prognostic awareness, and quality of life with CIIS. Design: We conducted a prospective, cross-sectional, multicenter study of patients with advanced HF receiving CIIS as palliative therapy between 2020 and 2022. Settings/Subjects: An investigator-developed survey instrument was administered to outpatients on CIIS in the United States via telephone. Measurements: Survey data were analyzed using descriptive and inferential statistics. Results: Forty-eight patients, 63% male, 81% African American/Black, with a mean age of 68.9 (standard deviation 12.3) years, participated in this study. The majority of patients responded that they expected CIIS to make them feel better (79%) and increase longevity (75%), but few expected that CIIS would cure their HF (19%). Patients described their overall quality of life on CIIS as not better/worse (19%), somewhat better (46%), and significantly better (35%) and reported high treatment satisfaction (87% were at least somewhat satisfied). Conclusions: In this study, patients report improved quality of life with CIIS as palliative therapy. Patients on CIIS as palliative therapy expected increased survival on CIIS, which is incongruent with current evidence. Further studies on how we can improve care processes so that patients have accurate prognostic and disease-state awareness, and receive goal concordant care, are warranted.

Benefits and Harms of Continuous Intravenous Inotropic Support as Palliative Therapy: A Single-Institution, Retrospective Analysis.

Use of continuous intravenous inotropic support (CIIS) strictly as palliative therapy for patients with ACC/AHA Stage D (end-stage) Heart Failure (HF) has increased significantly. The harms of CIIS therapy may detract from its benefits. To describe benefits (improvement in NYHA functional class) and harms (infection, hospitalization, days-spent-in-hospital) of CIIS as palliative therapy. Methods: Retrospective analysis of patients with end-stage HF initiated on CIIS as palliative therapy at an urban, academic center in the United States between 2014-2016. Clinical outcomes were extracted, and data were analyzed using descriptive statistics. Seventy-five patients, 72% male, 69% African American/Black, with a mean age 64.5 years (SD = 14.5) met study criteria. Mean duration of CIIS was 6.5 months (SD = 7.7). Most patients (69.3%) experienced improvement in NYHA functional class from class IV to class III. Sixty-seven patients (89.3%) were hospitalized during their time on CIIS, with a mean of 2.7 hospitalizations per patient (SD = 3.3). One-third of patients (n = 25) required at least one intensive care unit (ICU) admission while on CIIS therapy. Eleven patients (14.7%) experienced catheter-related blood stream infection. Patients spent an average of 20.6% (SD = 22.8), approximately 40 days, of their time on CIIS admitted to the study institution. Patients on CIIS as palliative therapy report improvement in functional class, survive 6.5 months following initiation, but spend a significant number of days in the hospital. Prospective studies quantifying the symptomatic benefit and the direct and indirect harms of CIIS as palliative therapy are warranted.

Racial And Ethnic Discrimination During Clinical Education and Its Impact on the Well-Being of Nurse Anesthesia Students.

The effects of racial/ethnic discrimination in the clinical setting have been shown to cause psychological distress in populations of healthcare workers. However, there are currently no published studies that investigate racial/ethnic transgressions in the clinical arena and their impact on the well-being of student registered nurse anesthetists (SRNAs). The current study aimed to investigate 1) the prevalence and nature of racial/ethnic bias during clinical education and 2) its impact on wellness in a cohort of SRNAs. Data were collected using a three-part 16-item electronic questionnaire distributed to a national sample of SRNAs. A significant association was found between race/ethnicity and an increased incidence of discrimination (χ2 [5] = 24.1, P < .001). SRNAs who described experiencing at least one discrimination encounter during their training had significantly higher mean Well-Being Index scores-associated with more distress-compared with those students who had never experienced discrimination (P < .05). Participant responses were categorized into five major themes: overt discrimination, covert discrimination, disparate treatment, barriers to reporting, and incivility/bullying. Addressing the distinctive challenges related to race/ethnicity in clinical sites is paramount to ensuring the success of minority SRNAs.

Assessing CRNA Knowledge of Local Anesthetic Systemic Toxicity Treatment.

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access (P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future.

A Retrospective Study: Multimodal Analgesia Quality Measure Implementation and Patient Outcome Assessment.

Current research has demonstrated that nonopioid multimodal analgesia decreases perioperative opioid consumption, postoperative nausea and vomiting (PONV), and pain scores. However, no research has been conducted to examine the patient outcomes of Merit-based Incentive Payment System (MIPS) 477. This study evaluates those outcomes following implementation of MIPS 477. The medical records of 400 adult patients who underwent elective and urgent laparoscopic gynecological procedures at a facility in the Mid-Atlantic region were reviewed. Data collection included patient characteristics, analgesics administered, pain scores at postanesthesia care unit (PACU) arrival and discharge, and antiemetic administration in PACU. This study's primary outcomes were postoperative pain scores, total intraoperative and postoperative opioid consumption, and PONV. Twenty-nine patients (7.8%) met the criteria as a control group, and 341 patients (92.2%) met the criteria as a treatment group. Pain scores were higher upon PACU arrival among the control group (P = .001). The total intraoperative morphine milligram equivalents (MMEs) administered was less among the treatment group (P = .04). The treatment group had reduced total intraoperative MMEs and pain scores at PACU arrival. However, there was no statistical significance in PACU discharge pain score, total PACU MMEs, and PONV in both groups.

Examination of a Nurse Anesthesia Program's Teaching Assistant Model and Its Impact on Increasing Nurse Anesthesia Education Capacity.

A nurse anesthesia educator shortage exists that is attributed to factors such as a lack of financial incentive and proper training to be an educator. Due to the faculty shortage, nurse anesthesia programs (NAPs) are forced to defer admission to qualified applicants which reduces the number of certified registered nurse anesthetists (CRNAs) that NAPs can produce. Research regarding students as teaching assistants (TAs) at the university level has shown benefits and challenges to students, professors, and the TAs themselves as well as the impact on the overall faculty capacity. Current research regarding TA programs does not pertain to NAPs, therefore, research regarding the impact of TA programs on increasing nurse anesthesia faculty merits further work. This study was conducted using quantitative surveys and qualitative interviews to bridge the gap in the literature on the potential impact of TA programs on NAP faculty shortages. A survey was sent via email to former TAs (n = 44) of the Georgetown University NAP to assess the impact that the TA program had on their decision to enter a role in academia after graduation. Interviews were then conducted on a voluntary basis via a video conferencing platform to add qualitative data to the survey results. The survey response rate was 45% (n = 20). Following proportional analysis, 80% of the survey respondents indicated that they participated in the education of student registered nurse anesthetists in the clinical or didactic setting as a CRNA. Eighty percent of respondents indicated that being a TA positively influenced their desire to become a faculty member. One hundred percent of CRNAs interviewed reported that the biggest barrier to becoming fulltime faculty was the lack of financial incentives offered by NAPs. Interviewees recalled their TA experience as the foundation for their enjoyment of teaching anesthesia. The results of this study indicate that TA programs in NAPs can be used as a method to increase faculty capacity.

Visual intelligence education using an art-based intervention: Outcomes evaluation with nursing graduate students.

BACKGROUND: Purposeful visual training is effective. Increasingly, visual arts learning interventions are used by multiple disciplines to improve observation and communication skills, critical skills in healthcare. PURPOSE: The primary aim was to evaluate enhancement of skills in the observation, perception and communication domains of visual literacy following a fine arts intervention with nursing graduate students. METHODS: An art-based intervention with five visual thinking activities was collaboratively developed with a faculty director of an arts and humanities program and museum arts educator and implemented at a gallery with 94 Post-Master's Doctor of Nursing Practice (DNP) students in advanced roles and Clinical Nurse Leader (CNL) entry-to-practice graduate students. Participation in the non-randomized, non-controlled quantitative study with pre- and post-evaluation design was voluntary. Prior to and following the session, 63 participants completed a Visual Intelligence Assessment (VIA) tool and 70 completed an Image Assessment exercise. RESULTS: Pre-intervention scores were similar for the two groups. Post intervention, DNP VIA mean scores increased from 3.58 to 3.68 (p = .057) while CNL mean VIA scores decreased from 3.65 to 3.53 (p = .08). DNP students had significantly higher image scores post-intervention (p < .001), demonstrating improved use of objective language. No difference was found in CNL image scores pre and post. CONCLUSIONS: The intervention increased self-awareness and perceived understanding of the role of VI on perception and empathy. DNP students also improved observational skills and language. Magnitude and direction of change in self-awareness appears relative to prior experience and skill.

Identifier Bouffants: An Exploration of the Impact on Verbal Communication Among Interdisciplinary Operating Room Personnel.

Effective team communication reduces errors in the perioperative environment and is an essential component of patient safety. Although name and title recognition are beneficial in enhancing communication, often members of the interdisciplinary team are unfamiliar with their colleagues. This lack of familiarity is worsened when the visual cue of a name badge is obscured under sterile scrub attire. The primary purpose of this quasi-experimental study was to explore whether or not the use of identifier bouffants, which provided a visual cue of the anesthesia provider's name and position on their forehead, impacted verbal communication and familiarity within the operating room team. Participation in this study was voluntary and data were collected using a twenty-five question Likert-Scale survey. A significant association was identified between the presence of an identifier bouffant in the operating room and self-reported increased communication amongst the interdisciplinary operating room team (z = 5.42, P <.001). Of the 72 participants meeting inclusion criteria, 59 (82%) agreed that verbal communication was enhanced by the use of identifier bouffants in the operating room. Further exploration of strategies to improve name and title recognition in the operating room setting are supported by the results of this study.

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy.

Background: Many patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients "crossover" from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy. Methods: Single-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics. Results: Of 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for "crossover" from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001). Conclusion: Patients on CIIS as bridge therapy who do not ultimately receive surgical therapy "crossover" to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these "bridge to nowhere" patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.

Ethical Challenges in Independent Living Donor Advocacy.

The Independent Living Donor Advocate, who is required on the transplant team, advocates, promotes, and protects the interests of the donor. Previously described ethical challenges perceived by these advocates and the variability of their responses prompted further inquiry. RESEARCH QUESTIONS: How are ethical obligations perceived by ILDAs? What ethical principles do ILDAs identify as the basis of their decision making? What are the ethical challenges for ILDAs? STUDY DESIGN: A descriptive cross-sectional survey was designed and administered via REDCap. Participants were recruited from the National Kidney Foundation Living Donor Advocate email list. Quantitative and qualitative data on their role, ethical decision making, and perceived ethical issues, by seriousness and frequency, were collected. RESULTS: Thirty-four participants responded. Nonmaleficence was ranked as the primary ethical principle used in decision making. Participants rated obligations to protect higher than advocacy. Participants reported experiencing internal ethical conflict to protect over advocate for the donor. The most serious ethical challenge participants perceived for donors was their decisional capacity, followed by their emotional or psychological distress, which was also described as a frequent donor challenge experienced in their role. DISCUSSION: The results of this survey validate previous descriptions that the advocate role is largely perceived as protective. Their independent nature as well as the inherent vulnerabilities of the potential living donor compels the continued mitigation of ethical challenges, to enhance advocacy and protection for the living donor.

Union Efforts to Reduce COVID-19 Infections Among Grocery Store Workers.

Grocery store workers are essential workers, but often have not been provided with appropriate protection during the current pandemic. This report describes efforts made by one union local to protect workers, including negotiated paid sick leave and specific safety practices. Union representatives from 319 stores completed 1612 in-store surveys to assess compliance between 23 April 2020 and 31 August 2020. Employers provided the union with lists of workers confirmed to have COVID-19 infection through 31 December 2020. Worker infection rates were calculated using store employees represented by the union as the denominator and compared to cumulative county infection rates; outcome was dichotomized as rates higher or lower than background rates. Restrictions on reusable bags and management enforcement of customer mask usage were most strongly associated with COVID-19 rates lower than rates in the surrounding county. Stores that responded positively to worker complaints also had better outcomes. The union is currently engaging to promote improved ventilation and vaccination uptake.