Coronavirus Disease 2019 (COVID-19) Prevalences Among People Experiencing Homelessness and Homelessness Service Staff During Early Community Transmission in Atlanta, Georgia, April-May 2020.

BACKGROUND: In response to reported coronavirus disease 2019 (COVID-19) outbreaks among people experiencing homelessness (PEH) in other US cities, we conducted multiple, proactive, facility-wide testing events for PEH living sheltered and unsheltered and homelessness service staff in Atlanta, Georgia. We describe the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) prevalence and associated symptoms, and review shelter infection prevention and control (IPC) policies. METHODS: PEH and staff were tested for SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR) during 7 April-6 May 2020. A subset of PEH and staff was screened for symptoms. Shelter assessments were conducted concurrently at a convenience sample of shelters using a standardized questionnaire. RESULTS: Overall, 2875 individuals at 24 shelters and 9 unsheltered outreach events underwent SARS-CoV-2 testing, and 2860 (99.5%) had conclusive test results. The SARS-CoV-2 prevalences were 2.1% (36/1684) among PEH living sheltered, 0.5% (3/628) among PEH living unsheltered, and 1.3% (7/548) among staff. Reporting fever, cough, or shortness of breath in the last week during symptom screening was 14% sensitive and 89% specific for identifying COVID-19 cases, compared with RT-PCR. Prevalences by shelter ranged 0-27.6%. Repeat testing 3-4 weeks later at 4 shelters documented decreased SARS-CoV-2 prevalences (0-3.9%). Of 24 shelters, 9 completed shelter assessments and implemented IPC measures as part of the COVID-19 response. CONCLUSIONS: PEH living in shelters experienced a higher SARS-CoV-2 prevalence compared with PEH living unsheltered. Facility-wide testing in congregate settings allowed for the identification and isolation of COVID-19 cases, and is an important strategy to interrupt SARS-CoV-2 transmission.

Shelter Characteristics, Infection Prevention Practices, and Universal Testing for SARS-CoV-2 at Homeless Shelters in 7 US Urban Areas.

Objectives. To examine shelter characteristics and infection prevention practices in relation to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection point prevalence during universal testing at homeless shelters in the United States.Methods. SARS-CoV-2 testing was offered to clients and staff at homeless shelters, irrespective of symptoms. Site assessments were conducted from March 30 to June 1, 2020, to collect information on shelter characteristics and infection prevention practices. We assessed the association between SARS-CoV-2 infection prevalence and shelter characteristics, including 20 infection prevention practices by using crude risk ratios (RRs) and exact unconditional 95% confidence intervals (CIs).Results. Site assessments and SARS-CoV-2 testing results were reported for 63 homeless shelters in 7 US urban areas. Median infection prevalence was 2.9% (range = 0%-71.4%). Shelters implementing head-to-toe sleeping and excluding symptomatic staff from working were less likely to have high infection prevalence (RR = 0.5; 95% CI = 0.3, 0.8; and RR = 0.5; 95% CI = 0.4, 0.6; respectively); shelters with medical services available were less likely to have very high infection prevalence (RR = 0.5; 95% CI = 0.2, 1.0).Conclusions. Sleeping arrangements and staffing policies are modifiable factors that might be associated with SARS-CoV-2 infection prevalence in homeless shelters. Shelters should follow recommended practices to reduce the risk of SARS-CoV-2 transmission.

Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters - Four U.S. Cities, March 27-April 15, 2020.

In the United States, approximately 1.4 million persons access emergency shelter or transitional housing each year (1). These settings can pose risks for communicable disease spread. In late March and early April 2020, public health teams responded to clusters (two or more cases in the preceding 2 weeks) of coronavirus disease 2019 (COVID-19) in residents and staff members from five homeless shelters in Boston, Massachusetts (one shelter); San Francisco, California (one); and Seattle, Washington (three). The investigations were performed in coordination with academic partners, health care providers, and homeless service providers. Investigations included reverse transcription-polymerase chain reaction testing at commercial and public health laboratories for SARS-CoV-2, the virus that causes COVID-19, over approximately 1-2 weeks for residents and staff members at the five shelters. During the same period, the team in Seattle, Washington, also tested residents and staff members at 12 shelters where a single case in each had been identified. In Atlanta, Georgia, a team proactively tested residents and staff members at two shelters with no known COVID-19 cases in the preceding 2 weeks. In each city, the objective was to test all shelter residents and staff members at each assessed facility, irrespective of symptoms. Persons who tested positive were transported to hospitals or predesignated community isolation areas.

Nebulous Intentioning - Acute hospital nurses' struggle to deliver core nursing care.

AIM: To explore the influences on nursing practice in acute hospital care. DESIGN: A Classic Grounded Theory study. METHODS: Data collection (2013-2015) was through interviews and non-participant observations. Analysis was undertaken using constant comparative data analysis and theoretical sampling. Memo writing was used as an aid to understanding and conceptualizing data during analysis. Theoretical coding served to integrate emerging concepts. RESULTS: This theory explains core nursing as a nebulous intention, an idea which acute care nurses retain throughout each shift, that they will nurse their patients fully when they have the opportunity. It reveals this as the resolution of their main problem which is the constant deferral of core nursing care. This study explains its two sub-core categories, accommodating and integrity eroding. CONCLUSION: The theory highlights nurses' attitudes towards their role, demonstrated by deferring it to accommodate the work of others, but offers a new perspective on the significant contribution nurses make to the safe and cohesive transition of patients through the acute healthcare system. IMPACT: The theory adds a new understanding of the unique contribution nurses make to patient health and safety in acute care environments. It also provides insight into nurses' attitudes towards their own professional work. It explains the consequences of attitudes which undermine core nursing when it competes for priority with accommodating. Accommodating indicates a greater workload for nurses than has been previously understood in explaining the activities, additional to core nursing care, which nurses undertake to contribute safety and cohesion to the patient's acute care journey. These new insights suggest a role for managers in recognizing accommodating in decisions about staffing and resources and for educators in improving the profession's regard for its theoretical underpinnings and for its self-image.

Care accommodation in the acute care setting: Missed care or not?

AIM: To explain how nurses care for patients with stroke in the acute setting, when working within constraints. BACKGROUND: Internationally, health care environments are experiencing constraints such as reduced staffing levels, and lack of time and resources. In such circumstances, patient care is often of poorer quality or missed entirely. METHOD(S): Classic grounded theory methodology was used to explain how care is provided within the acute care setting for patients following stroke. Data were collected using unstructured interviews with 32 nurses. RESULTS: Care accommodation, a typology of caring, was generated consisting of functional caring, assisted self-caring and ideal caring. Depending on the degree of constraint, nurses consciously or subconsciously prioritize care, potentially leading to missed care. CONCLUSION(S): Care accommodation elucidates what happens to care delivery with limited resources. Missed care may result from engaging with care accommodation, a factor that nurses and managers need to consider in care delivery. IMPLICATIONS FOR NURSING MANAGEMENT: Care accommodation provides new insight and understanding for management of the daily challenges nurses face, thus informing nursing management that supports nurses advocating at higher levels for resources to provide necessary environments and strategies to reduce missed care.

Nurses keeping patients safe by managing risk in perioperative settings: A classic grounded theory study.

AIM: To develop and expand how nurses promote safety in perioperative settings. BACKGROUND: This article presents orchestrating a sub-core category from the theory of anticipatory vigilance in promoting safety within preoperative settings (Journal of Clinical Nursing, 27, 2018, 247). Orchestrating explains this and involves effective planning, delegating, co-ordinating and communication. METHOD: A classic grounded theory methodology was used. Ethical approval was granted. Data comprised of 37 interviews and 33 hr of non-participant observation. Data analysis followed the principals of classic grounded theory. RESULTS: Orchestrating is fundamental in promoting safety and minimizing risk of errors and adverse events in the perioperative setting. Nurses achieve this through four categories: macro orchestrating, locational orchestrating, situational orchestrating and being in the know. CONCLUSION(S): Nurses minimize risk by fostering a culture of safety, risk awareness, effective management and leadership. IMPLICATIONS: Effective management structures and support systems are essential in promoting a culture of safety in perioperative setting.

Accommodating interruptions: A grounded theory of young people with asthma.

AIMS AND OBJECTIVES: The aim of this study was to develop an explanatory theory on the lives of young people with asthma, issues affecting them and the impact of asthma on their day-to-day lives. BACKGROUND: Accommodating Interruptions is a theory that explains young people's concerns about living with asthma. Although national and international asthma management guidelines exist, it is accepted that the symptom control of asthma among the young people population is poor. DESIGN: This study was undertaken using Classic Grounded Theory. METHODS: Data were collected through in-depth interviews and clinic consultations with young people aged 11-16 years who had asthma for over 1 year. Data were also collected from participant diaries. Constant comparative analysis, theoretical coding and memo writing were used to develop the substantive theory. RESULTS: The theory explains how young people resolve their main concern of being restricted by Accommodating Interruptions in their lives. They do this by assimilating behaviours in balance finding, moderating influence, fitting in and assuming control minimising the effects of asthma on their everyday lives. CONCLUSION: The theory of Accommodating Interruptions explains young people's asthma management behaviours in a new way. It allows us to understand how and why young people behave the way they do because they want to participate and be included in everyday activities, events and relationships. The theory adds to the body of knowledge on how young people with asthma live their day-to-day lives and it challenges some existing viewpoints in the literature regarding their behaviours. RELEVANCE TO CLINICAL PRACTICE: The findings have implications for developing services to support young people in a more meaningful way as they accommodate the interruptions associated with asthma in their lives.

Anticipatory vigilance: A grounded theory study of minimising risk within the perioperative setting.

AIMS AND OBJECTIVES: To explore and explain how nurses minimise risk in the perioperative setting. BACKGROUND: Perioperative nurses care for patients who are having surgery or other invasive explorative procedures. Perioperative care is increasingly focused on how to improve patient safety. Safety and risk management is a global priority for health services in reducing risk. Many studies have explored safety within the healthcare settings. However, little is known about how nurses minimise risk in the perioperative setting. DESIGN: Classic grounded theory. METHODS: Ethical approval was granted for all aspects of the study. Thirty-seven nurses working in 11 different perioperative settings in Ireland were interviewed and 33 hr of nonparticipant observation was undertaken. Concurrent data collection and analysis was undertaken using theoretical sampling. Constant comparative method, coding and memoing and were used to analyse the data. RESULTS: Participants' main concern was how to minimise risk. Participants resolved this through engaging in anticipatory vigilance (core category). This strategy consisted of orchestrating, routinising and momentary adapting. CONCLUSION: Understanding the strategies of anticipatory vigilance extends and provides an in-depth explanation of how nurses' behaviour ensures that risk is minimised in a complex high-risk perioperative setting. This is the first theory situated in the perioperative area for nurses. RELEVANCE TO CLINICAL PRACTICE: This theory provides a guide and understanding for nurses working in the perioperative setting on how to minimise risk. It makes perioperative nursing visible enabling positive patient outcomes. This research suggests the need for training and education in maintaining safety and minimising risk in the perioperative setting.

The effect of adult Early Warning Systems education on nurses' knowledge, confidence and clinical performance: A systematic review.

AIMS: This review aims to determine the effect of adult Early Warning Systems education on nurses' knowledge, confidence and clinical performance. BACKGROUND: Early Warning Systems support timely identification of clinical deterioration and prevention of avoidable deaths. Several educational programmes have been designed to help nurses recognize and manage deteriorating patients. Little is known as to the effectiveness of these programmes. DESIGN: Systematic review. DATA SOURCES: Academic Search Complete, CINAHL, MEDLINE, PsycINFO, PsycARTICLES, Psychology and Behavioral Science Collection, SocINDEX and the UK & Ireland Reference Centre, EMBASE, the Turning Research Into Practice database, the Cochrane Central Register of Controlled Trials (CENTRAL) and Grey Literature sources were searched between October and November 2015. REVIEW METHODS: This is a quantitative systematic review using Cochrane methods. Studies published between January 2011 - November 2015 in English were sought. The risk of bias, level of evidence and the quality of evidence per outcome were assessed. RESULTS: Eleven articles with 10 studies were included. Nine studies addressed clinical performance, four addressed knowledge and two addressed confidence. Knowledge, vital signs recording and Early Warning Score calculation were improved in the short term. Two interventions had no effect on nurses' response to clinical deterioration and use of communication tools. CONCLUSION: This review highlights the importance of measuring outcomes using standardized tools and valid and reliable instruments. Using longitudinal designs, researchers are encouraged to investigate the effect of Early Warning Systems educational programmes. These can include interactive e-learning, on-site interdisciplinary Early Warning Scoring systems training sessions and simulated scenarios.

Emotional resistance building: how family members of loved ones undergoing chemotherapy treatment process their fear of emotional collapse.

AIMS: To explore family members' experiences when their loved one is undergoing chemotherapy treatment as an outpatient for newly diagnosed colorectal cancer and to develop an explanatory theory of how they process their main concern. BACKGROUND: Most individuals with cancer are now treated as outpatients and cared for by family members. International research highlights the many side effects of chemotherapy, which in the absence of specific information and/or experience can be difficult for family members to deal with. Unmet needs can have an impact on the health of both patients and family members. DESIGN: Classic grounded theory methodology was used for this study. METHOD: Using classic grounded theory methodology, family members (n = 35) of patients undergoing chemotherapy treatment for cancer were interviewed (June 2010-July 2011). Data were analysed using the concurrent processes of constant comparative analysis, data collection, theoretical sampling and memo writing. FINDINGS: The main concern that emerged for participants was fear of emotional collapse. This fear was dealt with through a process conceptualized as 'Emotional Resistance Building'. This is a basic social process with three phases: 'Figuring out', 'Getting on with it' and 'Uncertainty adjustment'. The phases are not linear, but interrelated as participants can be in any one or more of the phases at any one time. CONCLUSION: This theory has the potential to be used by healthcare professionals working in oncology to support family members of patients undergoing chemotherapy. New ways of supporting family members through this most difficult and challenging period are articulated within this theory.

[Decision-making processes in nursing and activities at the end of life in intensive care­An international comparative study]. / Dialogisches Realisieren und Reorientieren--Pflegerische Entscheidungsfindungsprozesse und Aktivitäten am Lebensende auf der Intensivstation im internationalen Vergleich.

BACKGROUND: Intensive care units (ICUs) are traditionally settings that offer high technologically advanced treatment for those who are in critical situations due to an illness or accident. Questions regarding the withdrawal and withholding as well as the ending of life sustaining treatment are related to ethical dilemmas. Nurses' decision-making processes and nursing activities in different countries are scarcely studied. QUESTION: Which end-of-life decision-making processes and activities that are performed by nurses can be identified and described? AIM: The objective is the identification of a nursing terrain regarding decision-making and activities in patient end-of-life care on the intensive care unit. METHOD: Semi-structured interviews were conducted with 51 experienced nurses in university or hospital premises: 10 in Brazil, 9 in England, 10 in Germany, 10 in Ireland and 12 nurses in Palestine. The study used grounded theory to inform data collection and analysis. RESULTS: The finding of the study is the identification of a dynamic process in which activities with a focus on cure shift to activities with a focus on end-of-life care. The core category that emerged was 'negotiated reorienting': The shift of activities implies negotiations between nurses and physicians, relatives as well as with oneself. Moreover the process is characterized by a constant re-orientation that is induced by changing patient data and the realisation of the whole situation. Nurses' core practices are 'consensus seeking' and 'emotional holding' (sub-categories). CONCLUSIONS: In all countries a nursing terrain of activities in end-of-life care could be identified and described. However, it is unclear whether nursing activities connected to relatives of the patient are dominant in such a way that relations to dying patients and respect for their autonomy are put into the background. A field study could give answers to this question possible.

A review of oral preventative strategies to reduce ventilator-associated pneumonia.

AIM: This article evaluates the evidence for and efficacy of the use of mechanical hygiene and chlorhexidine in the prevention of ventilator-associated pneumonia (VAP). INCLUSION CRITERIA: primary research articles; randomized controlled trials; systematic reviews. EXCLUSION CRITERIA: quasi-experimental trials; opinion articles. Search Engines: PubMed; CINAHL; and EBSCO. BACKGROUND: VAP is the commonest infection found in critically ill patients who are mechanically ventilated. It is associated with increased mortality, increased length of stay in intensive care and increased costs. RELEVANCE TO CLINICAL PRACTICE: VAP is a health care-associated infection consistent with the presence of an endotracheal tube and mechanical ventilation for greater than 48 h. Efforts aimed at reducing infection rates include oral decontamination and mechanical hygiene to control the bacteria responsible, since there is an association between changes in bacteria found in the oropharynx and its development. Tooth brushing and the use of an oral antiseptic such as chlorhexidine gluconate are increasingly recommended in ventilator care bundles. CONCLUSION: While there have been a number of studies conducted evaluating the efficacy of both approaches, there is limited evidence to support their use. The frequency of oral decontamination and mechanical hygiene interventions have not been established and chlorhexidine 2% seems to be more effective compared to weaker concentrations, but data is mainly confined to patients following cardiothoracic surgery.

'It will dictate how many children I will have"- Women's decision-making in pregnancy following a previous caesarean birth (CB).

Vaginal birth after caesarean (VBAC) is supported in systematic reviews (Wu et al., 2019) and national guidelines (RCOG, 2015) and women are expected to be involved in the decision-making process for either a repeat caesarean birth or planned VBAC. AIM: To develop a Grounded Theory (GT) of women's decision making of their birth choices in pregnancy following a previous caesarean birth (CB) OBJECTIVE: To explore what determines women's birth choice and their decision making for birth following a previous CB. DESIGN: Semi structured interviews with pregnant women were undertaken in order to develop a Glasserian Grounded Theory SETTING: Antenatal clinics and wards in a large tertiary level maternity hospital. FINDINGS: The theory of 'Mentalizing Possibilities' is a substantive theory which explains pregnant women's decision making about their birth choices after a previous CB. Women's main concern is to achieve a positive experience. The core category of 'Mentalizing Possibilities' explains how women process their previous experience, adapt to uncertainty and deal with the decisional conflict. There are behavioural and cognitive strategies which women use to go through this process. CONCLUSION: Women want a positive birth experience after a previous CB and require support and continuity in decision making to help them decide the optimal birth choice for their current pregnancy.

What factors influence arterial blood gas sampling patterns?

STUDY OBJECTIVE: To investigate if patterns of arterial blood gas (ABG) sampling were influenced by values of fractional inspiratory oxygen (FiO2), partial pressure of carbon dioxide (PCO2), partial pressure of oxygen (PO2) and oxygen saturation (%SaO2). SETTING: An intensive care unit (ICU) in a university teaching hospital located in the North of England, UK. DESIGN: A retrospective, descriptive, correlation study based on patient records. PARTICIPANTS: All patients admitted to the ICU for 24 hours or greater and who had an arterial line in situ. MEASUREMENTS AND RESULTS: The study included the records of 65 patients consecutively admitted to the ICU. Patients in this study had more blood gases taken than reported elsewhere in the literature. While consistent correlation was found between values of FiO2, PCO2, PO2 and %SaO(2), values of PO2 were the most consistent. CONCLUSIONS: Values of PO2 are associated with frequency of ABG sampling and to a lesser extent on FiO2. Nurses in this study opted to track changes in oxygenation using ABGs despite continuous monitoring of %SaO2.

Playing the game: How young people moderate influences in accommodating asthma in their lives.

This article presents moderating influences, one of the sub-core categories from the theory of accommodating interruptions. This theory emerged in the context of young people who have asthma, explaining how they develop behaviours in their everyday lives (Hughes 2014; Hughes et al., 2017). The aim of this research was to develop a theory on the behaviours of young people who have asthma, in relation to the impact of asthma on the lives and the issues affecting them. This research was undertaken using a classic grounded theory approach. Data were collected through in-depth interviews, participant diaries and clinic consultations with young people aged 11-16 years who had asthma for over one year. Moderating influence accounts for how social influences and social culture affect what young people who have asthma wish to achieve and how they want to be perceived by others. Young people moderate influences by their features or attributes in order to meet their own needs.

Smartphones and mobile applications (apps) in clinical nursing education: A student perspective.

BACKGROUND: Nurse educators are exploring how mobile technology can support students in clinical practice. However, the view of nursing students on the use of smartphones and mobile applications (apps) to enhance clinical education has not been explored. Their opinions are vital to capture if the right technology is to be designed, evaluated, implemented and used. METHOD: A self-reported questionnaire, based on a review of the literature, was used to understand the opinions of undergraduate nursing students towards the use of smartphones and mobile apps to support learning in clinical environments. Descriptive statistics were utilised to describe participants and the mobile devices and apps they currently use. Thematic analysis was employed to code open-ended questions and explore students' perspective on how mobile apps can support learning and how best to implement and use them in practice. RESULTS: Two hundred nursing students across a four-year Bachelor of Nursing programme responded to the questionnaire. Most reported owning a smartphone but just under half used mobile apps to help them learn in clinical practice. A range of educational apps such as calculators, drug reference guides and medical dictionaries were used with varying frequency. Nursing students reported numerous benefits of mobile technology such as better access to educational material, improvements in knowledge and confidence, and reduced levels of anxiety around learning in practice. Barriers such as negative attitudes of nursing staff, poor Wi-Fi connectivity, and the quality of educational content available on mobile apps were identified as some of the issues preventing the adoption of mobile learning in clinical nursing education. CONCLUSIONS: Nursing students have a unique perspective on how smartphones and mobile apps can support learning in clinical practice. Nursing faculty need to undertake more rigorous research to determine if mobile technology can improve learning outcomes, how best to personalise mobile apps to students needs and ensure both hardware devices and educational software can be integrated in practice to support clinical training.

Using Co-Design with Nursing Students to Create Educational Apps for Clinical Training.

Mobile technology is being trialed in nursing education to support students in clinical practice, as it can provide instant access to high quality educational material at the point of care. However, most educational mobile apps are generic, off-the-shelf applications that do not take into consideration the unique needs of nursing students, who can require personalised software solutions. This study adapted a socio-cognitive engineering approach and through a series of focus groups with final year nursing students explored the co-design process and gained their input on the design and functionality of a clinical skills based educational app. Results showed students required an uncluttered interface that was fast to navigate and easy to use in busy clinical environments. They also requested simple visual descriptions of key clinical skills and equipment to enable them to quickly refresh their memory so they could perform the skill in practice.

Co-Designing Mobile Apps to Assist in Clinical Nursing Education: A Study Protocol.

Mobile applications (apps) to train health professionals is gaining momentum as the benefits of mobile learning (mLearning) are becoming apparent in complex clinical environments. However, most educational apps are generic, off-the-shelf pieces of software that do not take into consideration the unique needs of nursing students. The proposed study will apply a user-centred design process to create a tailored mobile app for nursing students to learn and apply clinical skills in practice. The app will be piloted and evaluated to understand how nursing students use mobile technology in clinical settings to support their learning and educational needs.

Nursing Students' Opinion on the Use of Smartphone Applications (Apps) in Clinical Education and Training: A Study Protocol.

Nurse educators are exploring different mobile technologies to provide additional support to nursing students in clinical practice. However, the view of nursing students on the use of smartphone applications (apps) to enhance clinical education has not been explored. This proposed study will use a self-reported questionnaire to examine the opinions of nursing students on the current and potential use of smartphone apps when training in clinical settings. Descriptive and inferential statistics will be performed on the quantitative data. Qualitative data from open ended questions will be thematically analysed using the framework approach. This will be the first study to examine the use of smartphone apps as a support in clinical teaching from a students' perspective. Their opinion is vital if the right mobile technology is to be designed and implemented.