Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice.

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

Factors Influencing Medication Administration Outcomes Among New Graduate Nurses Using Bar Code-Assisted Medication Administration.

Paramount to patient safety is the ability for nurses to make clinical decisions free from human error. Yet, the dynamic clinical environment in which nurses work is characterized by uncertainty, urgency, and high consequence, necessitating that nurses make quick and critical decisions. The aim of this study was to examine the influence of human and environmental factors on the decision to administer among new graduate nurses in response to alert generation during bar code-assisted medication administration. The design for this study was a descriptive, longitudinal, observational cohort design using EHR audit log and administrative data. The study was set at a large, urban medical center in the United States and included 132 new graduate nurses who worked on adult, inpatient units. Research variables included human and environmental factors. Data analysis included descriptive and inferential analyses. This study found that participants continued with administration of a medication in 90.75% of alert encounters. When considering the response to an alert, residency cohort, alert category, and previous exposure variables were associated with the decision to proceed with administration. It is important to continue to study factors that influence nurses' decision-making, particularly during the process of medication administration, to improve patient safety and outcomes.

Family history of substance problems among African Americans: Associations with drug use, drug use disorder, and prescription drug misuse.

A family history of substance problems is a well-known risk factor for substance use and use disorders; however, much of this research has been conducted in studies with predominantly White subjects. The aim of this study was to examine the associations between family history density of substance problems and drug use, risk for drug use disorder, and prescription drug misuse in a sample of African American adults. Results indicate that family history density of substance problems increased the risk for all drug outcomes in the full sample. However, when subgroup analyses by gender were conducted, family history was not a risk factor among men for prescription drug misuse.

Challenges and opportunities faced by nurse scientists in integrating data and technology in research to promote health equity.

Advances in technologies including omics, apps, imaging, sensors, and big data are increasingly being integrated into research by nurse scientists, but the impact on improving health equity is still unclear. In this article, nursing research faculty from one institution discuss challenges and opportunities experienced when integrating various technologies into their research aimed at promoting health equity. Using exemplars from faculty experiences, a three-pronged approach to keeping patients and communities and the goal of health equity central in research while incorporating advancing technologies is described. This approach includes establishing long-term engagement with populations underrepresented in research, adopting strategies to increase diversity in study participant recruitment, and training and collaboration among a diverse workforce of educators, clinicians, and researchers. Training nurse scientists in integrating data and technology for advancing the science on health equity will shift the culture of how we understand, collaborate, and grow with the communities in which we train and practice as nurse scientists.

Adverse Childhood Experiences Are Associated with Cardiometabolic Risk Indicators and Telomere Length in Low-Income African-American Adolescents.

BACKGROUND: Adverse childhood experiences (ACEs) have been linked to increased risk for cardiovascular disease later in life, and to shortened telomere length in children and adolescents, but few studies have examined associations between ACEs and cardiometabolic risk in adolescence or potential associations between ACEs, cardiometabolic risk indicators, and telomere length in this population. The present study examined competing models of associations between adolescent ACEs (as reported by mothers); cardiovascular, inflammatory, and metabolic indicators of health risk; and leukocyte telomere length in youth. METHOD: Data was collected from 108 low-income African-American adolescents (42.6% male; Mage = 14.27 years, SD = 1.17) living in the southeastern USA. Waist circumference was measured during a home interview, and measures of C-reactive protein, insulin resistance, and leukocyte telomere length were obtained from blood following overnight fasting. RESULTS: Path analysis supported a main effects model, whereby ACEs were significantly associated with shortened leukocyte telomere length, higher levels of C-reactive protein, and larger waist circumferences, controlling for maternal education and adolescent sex. Exploratory analyses examining whether cardiometabolic risk mediated associations between ACEs and telomere length, or whether telomere length mediated associations between ACEs and cardiometabolic risk, were not supported. CONCLUSIONS: ACEs are associated with risk of future cardiometabolic disorders and shortened leukocyte telomere length. Because cytogenetic changes are potentially modifiable, interventions to decrease family ACEs or alter responses to ACEs may lessen chronic disease risk in the African-American population. Targeted interventions to improve health are discussed.

Applying critical systems thinking to social prescribing: a relational model of stakeholder "buy-in".

BACKGROUND: Social prescribing (SP) allows health professionals to refer primary care patients toward health and wellbeing interventions and activities in the local community. Now widely implemented across the UK and adopted in other nations, questions arise concerning the modelling of present and future schemes, including challenges to full engagement encountered by stakeholders, which lie beyond the scope of traditional evaluations. Critical Systems Thinking (CST) allows for holistic analysis of fields where multiple stakeholders hold diverse interests and unequal power. METHODS: We use CST to (a) critically examine a developing rural social prescribing scheme from multiple stakeholder perspectives and (b) present a relational model for local social prescribing schemes. Our fieldwork included 24 in-depth interviews, regular planning meetings with key stakeholders, and discussions with those involved with national and international SP landscaping. A modified grounded theory approach was used for the analysis, and to consider the core elements of social prescribing sustainability. RESULTS: Our study confirms that local social prescribing schemes must operate with numerous stakeholder interests in mind, seeking to address real life social complexity and offer integrated solutions to multifaceted issues. Three main areas are discussed: holistic vision and boundary judgments; barriers and facilitators; relational issues and "emotional buy in". Problems for staff include selecting suitable clients, feedback and technological issues and funding and evaluation pressures. Barriers for clients include health, transport and expense issues, also lack of prior information and GP involvement. Emotional "buy-in" emerged as essential for all stakeholders, but hard to sustain. Based on our findings we propose a positive relational model comprising shared vision, confidence and commitment; motivation and encouragement, support and wellbeing focus, collaborative relationships, communication and feedback, access to information /resources, learning in and from action, with emotional "buy-in" at its heart. CONCLUSION: Those implementing social prescribing in different localities inevitably face hard choices about what and whom to include. Research on the sustainability of social prescribing remains limited, studies are required to ascertain which "holistic" models of social prescribing work best for which communities, who are the main beneficiaries of these approaches and how "buy-in" is best sustained.

Screening Tools to Predict the Development of Chronic Low Back Pain: An Integrative Review of the Literature.

OBJECTIVE: To identify and describe available instruments that can be used to screen patients with acute or subacute low back pain for a chronic low back pain trajectory. DESIGN: Integrative literature review. METHODS: An electronic search of PubMed/MEDLINE, CINAHL, Cochrane Database of Systematic Reviews, and PsychINFO databases took place from May through July of 2014 using systematic search strategies to identify screening instruments developed to identify people at risk of chronic low back pain. After screening for inclusion and exclusion criteria as well as quality indicators, the identified studies were categorized based on whether the instrument measured psychological, clinical, or functional measures to predict chronic low back pain. RESULTS: Initial searches identified 2,274 potential articles. After assessing for duplicates, title, and abstract content, there were 129 remaining articles. Articles were further excluded after analysis of the text, for a total of 42 studies reviewed. Most instruments reviewed were unable to provide evidence of predictive power for developing chronic low back pain. CONCLUSIONS: This review identified numerous instruments developed to assess the likelihood of chronic low back pain in acute and subacute low back pain populations. Of the instruments reviewed, the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Questionnaire demonstrated superior predictive power compared with other instruments. Both screening tools offer evidence of validation, translation into different languages and international application, and usage in various health care settings and provide data on predictive power.

Community Violence Exposure, Sleep Disruption, and Insulin Resistance in Low-Income Urban Adolescents.

BACKGROUND: Exposure to violence, which is experienced at disproportionally higher levels by black versus white youth, is associated with disruptions in sleep and elevated cardiovascular risk. Further, poor sleep hygiene is associated with insulin resistance. However, research to date examining disruptions in sleep and cardiovascular risk in African-American adolescents has not taken the impact of exposure to violence into account, nor considered how gender might affect patterns of association. The present study addressed this gap by testing a path model linking exposure to community violence, sleep disruption, and insulin resistance in a sample of African-American adolescents and evaluating model fit across gender. METHOD: African-American adolescents (N = 107; 56% female; Mage = 14.29, SD = 1.17) completed structured interviews at home and provided a blood sample after fasting overnight. RESULTS: The model fit connecting exposure to violence with sleep disruption and insulin resistance, adjusting for depressive symptoms and body mass index z score, was excellent. Multiple group analysis indicated gender differences in model fit. Path analysis revealed significant positive associations between exposure to violence and sleep disruption and sleep disruption and insulin resistance for females but not males. CONCLUSION: These data indicate that low-income, urban African-American female adolescents who witness violence and experience sleep disruptions may already be at elevated risk for health problems compared with their male counterparts. Additional research should attempt to replicate and explicate the underlying reasons for the gender differences observed here, with the goal of improving health and disrupting the path leading to health disparities.

Psychometric Evaluation of the Patient-Reported Outcomes Measurement Information System Fatigue-Short Form Across Diverse Populations.

BACKGROUND: The need for reliable, valid tools to measure patient-reported outcomes (PROs) is critical both for research and for evaluating treatment effects in practice. The Patient-Reported Outcomes Measurement Information System Fatigue-Short Form v1.0-Fatigue 7a (PROMIS F-SF) has had limited psychometric evaluation in various populations. OBJECTIVES: The aim of the study is to examine psychometric properties of PROMIS F-SF item responses across various populations. METHODS: Data from five studies with common data elements were used in this secondary analysis. Samples from patients with fibromyalgia, sickle cell disease, cardiometabolic risk, pregnancy, and healthy controls were used. Reliability was estimated using Cronbach's alpha. Dimensionality was evaluated with confirmatory factor analysis. Concurrent validity was evaluated by examining Pearson's correlations between scores from the PROMIS F-SF, the Multidimensional Fatigue Symptom Inventory-Short Form, and the Brief Fatigue Inventory. Discriminant validity was evaluated by examining Pearson's correlations between scores on the PROMIS F-SF and measures of stress and depressive symptoms. Known groups validity was assessed by comparing PROMIS F-SF scores in the clinical samples to healthy controls. RESULTS: Reliability of PROMIS F-SF scores was adequate across samples, ranging from .72 in the pregnancy sample to .88 in healthy controls. Unidimensionality was supported in each sample. Concurrent validity was strong; across the groups, correlations with scores on the Multidimensional Fatigue Symptom Inventory-Short Form and Brief Fatigue Inventory ranged from .60 to .85. Correlations of the PROMIS F-SF with measures of stress and depressive mood were moderate to strong, ranging from .37 to .64. PROMIS F-SF scores were significantly higher in clinical samples compared to healthy controls. DISCUSSION: Reliability and validity of the PROMIS F-SF were acceptable. The PROMIS F-SF is a suitable measure of fatigue across the four diverse clinical populations included in the analysis.

Integrative Review of Co-Occurring Symptoms Across Etiologies of Chronic Liver Disease and Implications for Symptom Management Research and Practice.

PURPOSE: Chronic liver disease affects over 30 million people worldwide, and despite advances in medical management that have increased survival, a majority of these individuals report multiple symptoms that severely impair function and quality of life. The purpose of this integrative review was to examine and summarize the current literature focused on self-reported symptoms in individuals with chronic liver disease in order to inform the development and delivery of symptom management strategies in clinical practice. DESIGN AND METHODS: Combinations of search terms related to the symptom experience were used to search three electronic databases. Inclusion criteria were empirical studies that measured self-reported symptoms in populations with chronic liver disease published in English between 2003 and 2014. The literature search initially yielded 112 results; 26 quantitative studies met the inclusion criteria. FINDINGS AND CONCLUSIONS: The symptom of fatigue was commonly reported across chronic liver disease populations and was often found to co-occur with other distressing symptoms, including depression, sleep disturbance, pain, cognitive impairment, and dizziness associated with autonomic dysfunction. Due to the high prevalence and persistence of these "core" symptoms, the use of core symptom measures integrated longitudinally across populations would inform the development and delivery of symptom management interventions as well as enhance the ability of nurses to incorporate population-level symptom management programs. CLINICAL RELEVANCE: Nurses play an important role in symptom assessment and may use the findings from the integrative review to incorporate core symptom measures across chronic liver disease populations and advance the development and delivery of symptom management interventions.

Developing a school nursing activity demand model Staffordhire.

Activity demand models for delivery of the Healthy Child Programme (HCP) through the school nursing workforce are limited. This paper describes the application of a potentially new activity demand model for school nursing. The model identifies what the demand for school nursing is in Staffordshire, using estimated delivery times of universal and targeted components from the HCP, numbers of children and local information around targeted activity, eg, numbers of looked after children. The model suggests that the school nursing service would spend around 60% of time on individual face to face activity, 30% on public health leadership, management and evaluation and the 10% on travel in Staffordshire. It also suggests a shortfall in workforce capacity. The model can be used to underpin commissioning decisions and service redesign and changes in practice would be required to meet the full requirements of the HCP.

Broadening their horizons: A rural and urban nursing student exchange program in primary care.

Educational strategies that allow students to experience patient care in both rural and urban settings are imperative to the recruitment and retention of nurses for medically underserved populations or health professional shortage areas. Two state schools of nursing (one urban-oriented and one rural-oriented) in the Mid-Atlantic region were awarded Health Resources and Service Administration (HRSA) project funding to educate nursing students and registered nurses in community-based primary care settings. This article will discuss an innovative rural-urban baccalaureate nursing student exchange model intended to increase understanding of enhanced RN roles in community-based primary care settings. Two project teams collaborated to create a new learning model, a rural-urban exchange, by implementing a Primary Care Camp. The camp included shared didactic content, reflection exercises, historical and cultural considerations, and clinical immersion to allow students in both programs to have on-site rural and urban learning experiences. Faculty collected informal voluntary student feedback through a debrief after their Primary Care Camp experience to assess their understanding of the enhanced RN Role in primary care and how it may affect their future nursing practice. Student feedback suggests that the students met project goals and appreciated the rural and urban exchange experience. This project is an innovative approach that offers guidance for implementing primary care education in a way that supports the current primary care RN role, builds the future workforce, and provides suggestions for replicability.

Text messaging as adjunct to community-based weight management program.

Increasing obesity rates are still a public health priority. The primary aim of this study was to evaluate the effect of tailored text messages on body weight change in overweight and obese adults in a community-based weight management program. A secondary aim was to detect behavioral changes in the same population. The study design was quasi-experimental with pretest and posttest analysis, conducted over 12 weeks. A total of 28 participants were included in the analysis. Body weight, eating behaviors, exercise and nutrition self-efficacy, attitude toward mobile technology, social support, and physical activity were assessed at baseline and at 12 weeks. Text messages were sent biweekly to the intervention but not to the control group. At 12 weeks, the intervention group had lost significant weight as compared with the control group. There was a trend toward an improvement in eating behaviors, exercise, and nutrition self-efficacy in the intervention group, with no significant difference between groups. A total of 79% of participants stated that text messages helped in adopting healthy behaviors. Tailored text messages appear to enhance weight loss in a weight management program at a community setting. Large-scale and long-term intervention studies are needed to confirm these findings.

Differential DNA Methylation and Cardiometabolic Risk in African American Mother-Adolescent Dyads.

BACKGROUND: Cardiovascular disease disproportionately affects African Americans as the leading cause of morbidity and mortality. Among African Americans, compared to other racial groups, cardiovascular disease onset occurs at an earlier age due to a higher prevalence of cardiometabolic risk factors, particularly obesity, hypertension and type 2 diabetes. Emerging evidence suggests that heritable epigenetic processes are related to increased cardiovascular disease risk, but this is largely unexplored in adolescents or across generations. MATERIALS AND METHODS: In a cross-sectional descriptive pilot study in low-income African American mother-adolescent dyads, we examined associations between DNA methylation and the cardiometabolic indicators of body mass index, waist circumference, and insulin resistance. RESULTS: Four adjacent cytosine and guanine nucleotides (CpG) sites were significantly differentially methylated and associated with C-reactive protein (CRP), 62 with waist circumference, and none to insulin resistance in models for both mothers and adolescents. CONCLUSION: Further study of the relations among psychological and environmental stressors, indicators of cardiovascular disease, risk, and epigenetic factors will improve understanding of cardiovascular disease risk so that preventive measures can be instituted earlier and more effectively. To our knowledge this work is the first to examine DNA methylation and cardiometabolic risk outcomes in mother-adolescent dyads.

Type 2 Diabetes Self-Management Variables and Predictors.

Guided by the Self and Family-Management framework, relationships between diabetes distress, self-efficacy, resilience and outcomes of A1c, quality of life and health status were explored. A cross-sectional descriptive design was used. Seventy eight individuals were enrolled from US clinics. Data were analyzed to test for associations, main effects and interactions and predictors of self-management. Results indicated low diabetes distress (M = 20.53), high self-efficacy (M = 7.32), moderate resilience (M = 80.27), and mean A1c 7.35%/56.88 mmol/mol. Seventy six percent of participants scored above the mental health norm, and 46% scored above the physical health norm. The average weighted quality of life score was -1.74. Diabetes distress was negatively associated with self-efficacy, resilience, physical health, mental health, and quality of life. Self-efficacy was positively associated with resilience, physical health, and quality of life. Resilience was positively associated with physical health, mental health and quality of life. Positive associations were found between quality of life, and physical and mental health. No associations were found between A1c and variables in the study. Multiple significant interactions were found with A1c, mental health and quality of life outcomes. Terms in the model included treatment regimen, years since diagnosis, provider collaboration, and history of diabetes self-management education. Distress was a significant predictor of health status and quality of life. The results confirm self-management facilitators self-efficacy and resilience and barrier diabetes distress and their relationships with outcomes in the framework. This study contributes to the understanding of the emotional aspect of diabetes. Continuing this work will allow researchers to better understand self-management, support self-management efforts and better outcomes.

Visual Arts in Nursing Education: An Inventive Interprofessional Initiative to Cultivate Metacognitive Awareness in Beginning Nursing Students.

PURPOSE: To test an interdisciplinary art-based educational program for beginning baccalaureate traditional and accelerated nursing students. DESIGN: Longitudinal study (Pretest-Posttest) of nursing students' metacognitive awareness. METHOD: As part of a first-semester foundations nursing course, all students participated in the Art of Nursing program consisting of three 90-minute sessions led by graduate Art Education students in a local fine arts museum. Before and after the program, subcomponents of critical thinking were assessed using the Metacognitive Awareness Inventory (MAI). FINDINGS: A total of 218 students (56 traditional, 162 accelerated) participated. Statistically significant improvement was observed on seven components of the MAI. Although significant increases were observed for Declarative (p < .0001), Planning (p < .0001), and Comprehension Monitoring (p < .0001), the differences pre to post were of different magnitudes between the student groups, characterizing a large change in the traditional versus accelerated group. CONCLUSIONS: Our results suggest that (1) nursing students' metacognitive awareness benefits from the museum-based experience despite demographic and educational differences and (2) overall the accelerated student group has exhibited higher metacognitive awareness at baseline as compared with the traditional student group; however, both groups demonstrate significant growth in this area after experiencing an art-based program.

Diabetes Engagement and Activation Platform for Implementation and Effectiveness of Automated Virtual Type 2 Diabetes Self-Management Education: Randomized Controlled Trial.

BACKGROUND: Patients with type 2 diabetes require recommendations for self-management education and support. OBJECTIVE: In this study, we aim to design the Diabetes Engagement and Activation Platform (DEAP)-an automated patient education tool integrated into primary care workflow-and examine its implementation and effectiveness. METHODS: We invited patients aged 18-85 years with a hemoglobin A1c (HbA1c) level ≥8 to participate in a randomized controlled trial comparing DEAP with usual care. DEAP modules addressing type 2 diabetes self-management education and support domains were programmed into patient portals, each with self-guided educational readings, videos, and questions. Care teams received patient summaries and were alerted to patients with low confidence or requesting additional help. HbA1c, BMI, and systolic and diastolic blood pressure (DBP) were measured. RESULTS: Out of the 680 patients invited to participate, 337 (49.5%) agreed and were randomized. All of the 189 intervention patients accessed the first module, and 140 patients (74.1%) accessed all 9 modules. Postmodule knowledge and confidence scores were high. Only 18 patients requested additional help from the care team. BMI was lower for intervention patients than controls at 3 months (31.7 kg/m2 vs 32.1 kg/m2; P=.04) and 6 months (32.5 kg/m2 vs 33.0 kg/m2; P=.003); improvements were even greater for intervention patients completing at least one module. There were no differences in 3- or 6-month HbA1c or blood pressure levels in the intent-to-treat analysis. However, intervention patients completing at least one module compared with controls had a better HbA1c level (7.6% vs 8.2%; P=.03) and DBP (72.3 mm Hg vs 75.9 mm Hg; P=.01) at 3 months. CONCLUSIONS: The findings of this study concluded that a significant proportion of patients will participate in an automated virtual diabetes self-management program embedded into patient portals and health systems show promise in helping patients manage their diabetes, weight, and blood pressure. TRIAL REGISTRATION: ClinicalTrials.gov NCT02957721; https://clinicaltrials.gov/ct2/show/NCT02957721.

Stress and Coping Profiles and Cardiometabolic Risk in Low-Income African American Women.

Background: The complex interplay of psychological stress appraisal, biology, chronically stressful environments, and individual coping mechanisms can impact and tax physiological adaptive processes. This can result in increased cardiometabolic risk (CMR), type 2 diabetes, and cardiovascular disease. Underlying mechanisms are not entirely clear and appear to differ significantly based on age, sex, race, and ethnicity. This crosssectional descriptive study explored stress profiles of psychological and behavioral adjustment to determine the extent to which patterns of stressors, coping, and CMR differentiated these profiles. Materials andMethods: African American (AA) women (N = 110; M age = 38.61 years, SD = 6.94 years) were recruited from low-income communities and participated in two home visits to complete stress and coping and cardiovascular risk measures. Results: Three distinct stress and coping adjustment profiles were associated with differences in CMR. The "holding steady" profile had less insulin resistance (IR) and substance use compared to "high substance users" and "high internalizers" profiles. Women who were "holding steady" used less avoidant coping than "high internalizers." Conclusions: Less favorable adjustment processes were associated with IR, as well as significantly higher levels of avoidant coping and substance use. In AA women, awareness of and attention to stress and coping patterns may help attenuate CMR.

Treatment Fidelity in Mind-Body Interventions.

PURPOSE: To contribute to the treatment fidelity literature by providing real-world examples and suggestion for future research and potential clinical application, this article reports on implementation, assessment, and evaluation of treatment fidelity in mind-body self-care approaches in at-risk women. METHOD: Aligning with best practices, treatment fidelity was integrated into three randomized clinical trials. The first examined the effects of a tai chi intervention designed to decrease cardiometabolic risk factors in women; the second examined the effects of a tailored guided imagery intervention on pregnancy outcomes in African American women; and the third explored effects of a mindful physical activity intervention (yoga) on psychological outcomes in women with moderate to severe depressive symptoms. FINDINGS: Each of the studies successfully designed, implemented, and evaluated strategies to address recommended treatment fidelity components. These strategies provided qualitative and quantitative data that informed intervention refinement, directions for future research, and application in clinical practice. CONCLUSIONS: The treatment fidelity framework used here is based on best practices and was a feasible and reliable approach for ensuring and reporting on treatment fidelity, which is contributing to future research to foster translation of potentially effective mind-body self-care approaches into practice.

Self and Family Management in Type 2 Diabetes: Influencing Factors and Outcomes.

Type 2 diabetes impacts over 30 million Americans and that number is increasing. Fundamental to optimal Type 2 diabetes control and improved health outcomes consists is effective self-management. There are several factors that promote and inhibit sustained and effective self-management. The established and evidence-based self and family management framework is proposed here as a solution for guiding research and practice to improve self-management and outcomes in patients with Type 2 diabetes.