Conceptualizing college-going volition in rural Appalachian high school students.

Understanding the gap between students' aspirations for postsecondary education and their actual postsecondary attainment is key to understanding and reducing educational and vocational inequities. Just as work volition has emerged as a key factor in understanding access to decent work, students' sense of control over or volition in the college-going process may be a key factor in understanding their access to postsecondary education. In the current study, we adapted a common measure of work volition to create a measure of college-going volition (CGV). In a large sample of rural Appalachian high school students, the measure showed good psychometric properties and strong measurement invariance across gender and prospective college-generation groups. There were no gender differences in CGV, but prospective first-generation college students demonstrated significantly lower CGV than their continuing-generation peers. CGV also accounted for significant unique variance in college-going self-efficacy beyond educational barriers.

Trends in Robot-Assisted Procedures for General Surgery in the Veterans Health Administration.

INTRODUCTION: Implementation of robot-assisted procedures is growing. Utilization within the country's largest healthcare network, the Veterans Health Administration, is unclear. METHODS: A retrospective cohort study using data from the Department of Veterans Affairs Corporate Data Warehouse from January 2015 through December 2019. Trends in robot utilization for cholecystectomy, ventral hernia repair, and inguinal hernia repair were characterized nationally and regionally by Veterans Integrated Services Network. Patients, who underwent laparoscopic repairs for these procedures and open hernia repairs, were included to determine proportion performed robotically. RESULTS: We identified 119,191 patients, of which 5689 (4.77%) received a robotic operation. The proportion of operations performed robotically increased from 1.49% to 10.55% (7.08-fold change; slope, 2.14% per year; 95% confidence interval [0.79%, 3.49%]). Ventral hernia repair had the largest growth in robotic procedures (1.51% to 13.94%; 9.23-fold change; slope, 2.86% per year; 95% confidence interval [1.04%, 4.68%]). Regions with the largest increase in robotic utilization were primarily along the Northeast, Midwest, and West Coast. CONCLUSIONS: Robot utilization in general surgery is increasing at different rates across the United States in the Veterans Health Administration. Future studies should investigate the regional disparities and drivers of this approach.

Development and Validation of a Short Form of the College-Going Self-Efficacy Scale.

Social Cognitive Career Theory (Lent et al., 1994) is a useful framework for understanding educational attainment and reducing educational inequities. A key construct for middle and high school students is college-going self-efficacy. The College-Going Self-Efficacy Scale (CGSES; Gibbons & Borders, 2010a) has been used to measure secondary students' confidence in their abilities to attend and persist in post-secondary education, but with 30-items, it may be too lengthy for use with other measures in SCCT-grounded research in school settings. Using two independent samples of rural Appalachian high school students, we develop and validate the College-Going Self-Efficacy Scale-Short Form (CGSES-SF). This 14-item measure retains the full breadth of content from the original CGSES, demonstrates measurement equivalence across gender and prospective college generation status, and demonstrates good reliability and validity in these samples. Suggestions for future use of the CGSES-SF are provided.

Assessing Postsecondary Barriers for Rural Appalachian High School Students.

Social cognitive career theory indicates that perceived barriers negatively affect career and educational self-efficacy beliefs and may also impact interests, goals, and actions. However, measurement of barriers has produced mixed results, and few quantitative studies explore the perceived barriers of rural Appalachian students. In this series of studies, we explored the perceived educational and career barriers of rural Appalachian high school students. Our goal was to identify perceived barriers, but as initial results were analyzed, we then shifted to how best to measure barriers and how culture impacted the reporting of barriers by rural Appalachian students. The results of our mixed-method series of studies offer ideas on how cultural values and beliefs may skew reporting of contextual influences on career and education.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Knee Arthroplasty.

Enhanced recovery after surgery (ERAS) has rapidly gained popularity in a variety of surgical subspecialities. A large body of literature suggests that ERAS leads to superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost benefits, without affecting rates of readmission after surgery. These patterns have been described for patients undergoing elective total knee arthroplasty (TKA); however, adoption of ERAS to orthopedic surgery has lagged behind other surgical disciplines. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute (AI) for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. The program comprises a national effort to incorporate best practice in perioperative care and improve patient safety, for over 750 hospitals and multiple procedures over the next 5 years, including orthopedic surgery. We have conducted a full evidence review of anesthetic interventions to derive anesthesiology-related components of an evidence-based ERAS pathway for TKA. A PubMed search was performed for each protocol component, focusing on the highest levels of evidence in the literature. Search findings are summarized in narrative format. Anesthesiology components of care were identified and evaluated across the pre-, intra-, and postoperative phases. A summary of the best available evidence, together with recommendations for inclusion in ERAS protocols for TKA, is provided. There is extensive evidence in the literature, and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for TKA.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Colorectal Surgery.

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery (ISCR), which is a national effort to disseminate best practices in perioperative care to more than 750 hospitals across multiple procedures in the next 5 years. The program will integrate evidence-based processes central to enhanced recovery and prevention of surgical site infection, venous thromboembolic events, catheter-associated urinary tract infections with socioadaptive interventions to improve surgical outcomes, patient experience, and perioperative safety culture. The objectives of this review are to evaluate the evidence supporting anesthesiology components of colorectal (CR) pathways and to develop an evidence-based CR protocol for implementation. Anesthesiology protocol components were identified through review of existing CR enhanced recovery pathways from several professional associations/societies and expert feedback. These guidelines/recommendations were supplemented by evidence made further literature searches. Anesthesiology protocol components were identified spanning the immediate preoperative, intraoperative, and postoperative phases of care. Components included carbohydrate loading, reduced fasting, multimodal preanesthesia medication, antibiotic prophylaxis, blood transfusion, intraoperative fluid management/goal-directed fluid therapy, normothermia, a standardized intraoperative anesthesia pathway, and standard postoperative multimodal analgesic regimens.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Bariatric Surgery.

Enhanced recovery after surgery protocols for bariatric surgery are increasingly being implemented, and reports suggest that they may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after bariatric surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, opioid minimization and multimodal analgesia, protective ventilation strategy, fluid minimization), and postoperative (multimodal analgesia with opioid minimization) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for enhanced recovery after surgery for bariatric surgery. There is evidence in the literature, and from society guidelines, to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for bariatric surgery.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Hip Arthroplasty.

Successes using enhanced recovery after surgery (ERAS) protocols for total hip arthroplasty (THA) are increasingly being reported. As in other surgical subspecialties, ERAS for THA has been associated with superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost savings. Nonetheless, the adoption of ERAS to THA has not been universal. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after THA. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, ventilation, tranexamic acid, fluid minimization, glycemic control), and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for THA. There is evidence in the literature and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for THA.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery.

Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.

Rural Appalachian High School Students' College-Going and STEMM Perceptions.

The authors examined perceptions of key social cognitive career theory (Lent, Brown, & Hackett, 1994) variables related to college-going and science, technology, engineering, math, and medical (STEMM) careers in 10th and 11th graders (N = 892) attending 3 rural Appalachian high schools. The authors examined differences in perceptions related to gender, prospective 1st-generation college student status, and the presence or absence of aspirations to pursue a STEMM career. Young women and young men scored similarly on all but 1 dependent variable, college-going self-efficacy (young women scored higher). Students who had STEMM career aspirations had higher scores on every measure than those who did not. Results suggest examining a 3rd prospective 1st-generation college student status group-students who are unsure of their parents' education level-as a distinct group in future research. By examining the college-going and STEMM attitudes of rural Appalachian high school students, this study advances the literature and informs practitioners on reducing educational and vocational inequalities in this region.

"Knowing I Had Someone to Turn to Was a Great Feeling": Mentoring Rural-Appalachian STEM Students.

Post-secondary students benefit from mentorships, which provide both emotional and academic support tailored to the unique challenges they face. STEM students, and, in particular, those with historically marginalized identities, have unique strengths and face distinct barriers that can be ameliorated by careful, knowledgeable, and well-situated mentoring relationships. With that in mind, we conducted a narrative case study with 10 rural-Appalachian STEM majors enrolled in an NSF-funded mentoring program, intending to collect stories of their impactful experiences with their mentors. We utilized the narrative reconstruction process, and, in so doing, identified five major themes related to the importance of mentor assignment and the impact of mentors' characteristics and skills related to empathy, consistency, active listening, and teaching. We situate our findings within the existing literature and provide implications for scholars and practitioners who work with mentoring programs dedicated to working with Appalachian communities.

Understanding group leader affect as a factor for career education programming.

The purpose of this study was to explore how group leader affect impacted facilitation of a career education program. Through a case study design, data were gathered via focus groups and blog posts from 16 program staff members. Five major themes were derived, highlighting group leader affect and experience: Emotions During Intervention, Flexibility, Student Engagement and Connections, Support from Program Staff, and School Culture. The findings encouraged career educators to remain flexible when delivering programming, to consider regular evaluations of affect throughout career programming, and to acknowledge the reciprocity of engagement, affect, and programmatic buy-in between facilitators and participants.

Le but de cette étude était d'explorer comment l'affect du leader de groupe influence l'impact d'un programme d'éducation au choix de carrière. Par le biais d'une étude de cas, les données ont été recueillies par des focus group et des post dans des blogs de 16 membres du personnel du programme. Cinq thèmes principaux ont été dégagés, mettant en évidence l'affect et l'expérience du leader de groupe: Les émotions pendant l'intervention, la flexibilité, l'engagement et les liens avec les étudiantes, le soutien du personnel du programme et la culture de l'école. Les résultats encouragent les professionnels à rester flexibles lors de la mise en œuvre des programmes, à envisager des évaluations régulières de l'affect tout au long des programmes de choix de carrière et à reconnaître la réciprocité de l'engagement, de l'affect et de l'adhésion au programme entre les intervenantes et les participantes.

El propósito de este estudio fue explorar cómo el afecto del líder grupal impactó en la impartición de un programa de educación vocacional. A través de un diseño de estudio de caso, se recopilaron datos a través de grupos focales y publicaciones en blog procedentes de 16 miembros del personal del programa. Se obtuvieron cinco temas principales, destacando el afecto y la experiencia del líder del grupo: emociones durante la intervención, flexibilidad, participación y relaciones de los estudiantes, apoyo del personal del programa y cultura escolar. Los hallazgos alentaron a los educadores vocacionales a permanecer flexibles al entregar la programación, a incluir evaluaciones periódicas del afecto a lo largo de la programación de la carrera y a reconocer la reciprocidad del compromiso, el afecto y la aceptación mutua del programa entre los facilitadores y los participantes.

Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study.

OBJECTIVE: To assess inequities in mortality by race and sex for eight common surgical procedures (elective and non-elective) across specialties in the United States. DESIGN: Retrospective cohort study. SETTING: US, 2016-18. PARTICIPANTS: 1 868 036 Black and White Medicare beneficiaries aged 65-99 years undergoing one of eight common surgeries: repair of abdominal aortic aneurysm, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection. MAIN OUTCOME MEASURE: The main outcome measure was 30 day mortality, defined as death during hospital admission or within 30 days of the surgical procedure. RESULTS: Postoperative mortality overall was higher in Black men (1698 deaths, adjusted mortality rate 3.05%, 95% confidence interval 2.85% to 3.24%) compared with White men (21 833 deaths, 2.69%, 2.65% to 2.73%), White women (21 847 deaths, 2.38%, 2.35% to 2.41%), and Black women (1631 deaths, 2.18%, 2.04% to 2.31%), after adjusting for potential confounders. A similar pattern was found for elective surgeries, with Black men showing a higher adjusted mortality (393 deaths, 1.30%, 1.14% to 1.46%) compared with White men (5650 deaths, 0.85%, 0.83% to 0.88%), White women (4615 deaths, 0.82%, 0.80% to 0.84%), and Black women (359 deaths, 0.79%, 0.70% to 0.88%). This 0.45 percentage point difference implies that mortality after elective procedures was 50% higher in Black men compared with White men. For non-elective surgeries, however, mortality did not differ between Black men and White men (1305 deaths, 6.69%, 6.26% to 7.11%; and 16 183 deaths, 7.03%, 6.92% to 7.14%, respectively), although mortality was lower for White women and Black women (17 232 deaths, 6.12%, 6.02% to 6.21%; and 1272 deaths, 5.29%, 4.93% to 5.64%, respectively). These differences in mortality appeared within seven days after surgery and persisted for up to 60 days after surgery. CONCLUSIONS: Postoperative mortality overall was higher among Black men compared with White men, White women, and Black women. These findings highlight the need to understand better the unique challenges Black men who require surgery face.

Experiences of Doctor of Nursing Practice (DNP)-prepared nurses choosing to pursue a Doctor of Philosophy (PhD) degree.

BACKGROUND: Increasingly, nurses with a Doctor of Nursing Practice (DNP) degree are seeking a Doctor of Philosophy (PhD) degree. This subset of students may provide valuable insight for bolstering the PhD-prepared workforce, which is in decline. PURPOSE: The purpose of this research was to understand the essence of the lived experience of DNP-prepared nurses choosing to pursue a PhD degree. METHOD: An existential phenomenological study was undertaken, with 10 DNP-to-PhD students interviewed. RESULTS: The DNP-to-PhD experience is about being On a Mission. The Nursing Hierarchy was an implicit force influencing students' missions, and their experiences were characterized by five themes: (a) Having Needs the DNP Can't Meet: "I had to go back and do more," (b) Considering Dreams and Circumstances: "Now's the time," (c) Developing Confidence: "You can do this!" (d) "I've been very supported"/"I had no support," and (e) "It had to be an internal drive for me." CONCLUSIONS: Study findings demonstrate profound effects of the nursing hierarchy on students' decisions as well as misperceptions that still surround DNP and PhD education and careers. Nursing academicians, organizational leaders, and researchers must address PhD program disinterest, intimidation, and imposter syndrome and improve messaging about both degrees.

Evaluation of clinical outcomes with alvimopan in clinical practice: a national matched-cohort study in patients undergoing bowel resection.

OBJECTIVE: To evaluate in-hospital clinical outcomes after open and laparoscopic bowel resection (BR) with or without alvimopan treatment. BACKGROUND: Delayed return of gastrointestinal function after BR may be associated with greater postoperative morbidity and increased hospital length of stay (LOS). In clinical trials, alvimopan--a peripherally acting µ-opioid receptor antagonist--accelerated gastrointestinal recovery after open BR. METHODS: A retrospective matched-cohort study (NCT01150760) was conducted using a national inpatient database. Each alvimopan patient was exact matched (surgical procedure, surgeon specialty) and propensity score matched (baseline characteristics) to a nonalvimopan BR patient. Outcomes included gastrointestinal and other morbidity (cardiovascular, pulmonary, infection, cerebrovascular, thromboembolic); mortality; readmission rate; and intensive care unit (ICU) stay (intent-to-treat [ITT] population). Postoperative LOS and estimated cost were also compared (modified ITT population). RESULTS: Each cohort included 3525 ITT patients with similar baseline characteristics. Gastrointestinal (29.8% vs 35.7%) and other morbidity (cardiovascular [19.4% vs 24.0%], pulmonary [7.3% vs 10.5%], infectious [9.6% vs 11.8%], thromboembolic [1.2% vs 2.1%]), mortality (0.4% vs 1.0%), and mean ICU stay (0.3 vs 0.6 days) were lower in the alvimopan group (P ≤ 0.003 for each). Postoperative LOS and estimated direct cost were lower for all alvimopan patients and after laparoscopic and open BR (LOS: -1.1, -0.8, and -1.8 days respectively; cost: -$2345, -$1382, and -$3218, respectively; P ≤ 0.0008 for each). CONCLUSIONS: On average, alvimopan-treated patients had a lower incidence of mortality and most incidents of morbidities. Length of stay, ICU use, and estimated cost were also lower with comparable readmissions. These results in patients outside the clinical trial setting include laparoscopic colectomy and demonstrate a potential association between acceleration of gastrointestinal recovery and improved early postoperative outcomes.

Validation of the College Planning Behaviors Scale.

College preparation is an important topic in the educational attainment of high school students. Much of the research on college planning focuses on the importance and timing of preparing for postsecondary education; however, little research has explored the steps students actually take while preparing for college. The current study utilized the Social Cognitive Career Theory (SCCT) framework to create a validated measure to assess choice behavior. The purpose of the current study was to create a validated measure for choice actions that could be used with diverse student groups. The measure was found to demonstrate good reliability and validity in this population, providing strong internal consistency and construct validity. Further, these findings support college-planning behaviors' linkage to barriers, college-going self-efficacy, and college outcome expectations (COE).

Evaluation of an SCCT-Based Intervention to Increase Postsecondary Awareness in Rural Appalachian Youth.

Students underrepresented in higher education often require unique support throughout their career and college planning. Rural Appalachian youth characterize a large population of underrepresented students. This article describes a theory-based multiweek career education curriculum aimed at increasing career and college readiness that was delivered to over 1,300 high school students in two rural Appalachian counties. Evaluation data from 867 of these students, as well as from the program staff, are provided. Findings suggest that participants found the intervention useful, learned new information about postsecondary planning and career exploration, and received assistance planning for their futures. Implications for school-based career education with underrepresented students, in general, are discussed.

Building on Strengths While Addressing Barriers: Career Interventions in Rural Appalachian Communities.

This article describes a model for developing culturally-sensitive career education programs, framed from an ecological contextual understanding (Bronfenbrenner, 1979). This framework allows career practitioners to build on cultural strengths and values to meet the career education needs of diverse communities. To illustrate the application of this model, we describe the cultural context of rural Appalachia and offer theoretically-framed ideas of how to meet the population's career education needs.

Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery.

Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.

Hyperglycemia Is Associated with Surgical Site Infections among General and Vascular Surgery Patients.

Surgical site infection (SSI) is a common cause of morbidity in general and vascular surgery patients. There is inconsistent evidence on the association of glycemic status with SSI, and its utility in predicting and mitigating SSI. General and vascular surgery patients at a public teaching hospital had the following markers of glycemic status prospectively collected: preoperative hemoglobin A1c (HbA1c) and capillary blood glucose (cBG, within six months before surgery), perioperative cBG (within 24 hours before surgery), and postoperative cBG (peak value up to 48 hours after surgery). Patient records were assessed for SSI within 30 days of surgery. Over a two-month period, 229 patients underwent surgery. The overall SSI rate was 9.6 per cent. Preoperative HbA1c >7 per cent and postoperative cBG ≥180 mL/dL occurred in 25.9 and 27.0 per cent of patients, respectively. Preoperative HbA1c >7 per cent was significantly associated with SSI [odds ratio (OR) 2.26, 80 per cent confidence interval (CI) 1.01-5.07], as was postoperative cBG ≥180 mg/dL (OR 2.12, 80 per cent CI 1.02-4.41). There was no significant correlation between preoperative or perioperative cBG and SSI. In conclusion, SSI and hyperglycemia were frequent among the study population, and positively associated. Glycemic status may be used for improved preoperative risk assessment, and as it is potentially mutable, to reduce SSI.