Themes of Liminality: Stories From Cancer Family Caregiver Narratives.

Cancer family caregivers dwell in an evolving landscape of ambiguity and in-betweenness, as "betwixt and between," in a space of unknowing. This space of unknowing exists within a transformational threshold of liminality, between what was known prior to the cancer and what will be known and embodied in the future. Theoretically grounded in Unitary Caring Science, this study used narrative inquiry alongside photo elicitation to cocreate cancer caregiver narratives and identify themes of liminality. Four thematic threads of liminality were identified as woven within and across the cancer caregiver narratives; stories of paradox, time warp, life disruption, and waiting in silence.

Sudden Shift to Telehealth in COVID-19: A Retrospective Cohort Study of Disparities in Use of Telehealth for Prenatal Care in a Large Midwifery Service.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic created disruption in health care delivery, including a sudden transition to telehealth use in mid-March 2020. The purpose of this study was to examine changes in the mode of prenatal care visits and predictors of telehealth use (provider-patient messaging, telephone visits, and video visits) during the COVID-19 pandemic among those receiving care in a large, academic nurse-midwifery service. METHODS: We conducted a retrospective cohort study of those enrolled for prenatal care in 2 nurse-midwifery clinics between 2019 and 2021 (n = 3172). Use outcomes included number and type of encounter: in-person and telehealth (primary outcome). Comparisons were made in frequency and types of encounters before and during COVID-19. A negative binomial regression was fit on the outcome of telehealth encounter count, with race/ethnicity, age, language, parity, hypertension, diabetes, and depression as predictors. RESULTS: When comparing pre-COVID-19 (before March 2020) with during COVID-19 (after March 2020), overall encounters increased from 15.9 to 19.5 mean number of encounters per person (P < .001). The increase was driven by telehealth encounters; there were no significant differences for in-person prenatal visit counts before and during the pandemic period. Direct patient-provider messaging was the most common type of telehealth encounter. Predictors of telehealth encounters included English as primary language and diagnoses of diabetes or depression. DISCUSSION: No differences in the frequency of in-person prenatal care visits suggests that telehealth encounters led to more contact with midwives and did not replace in-person encounters. Spanish-speaking patients were least likely to use telehealth-delivered prenatal care during the pandemic; a small, but significant, proportion of patients had no or few telehealth encounters, and a significant proportion had high use of telehealth. Integration of telehealth in future delivery of prenatal care should consider questions of equity, patient and provider satisfaction, access, redundancies, and provider workload.

Theory Analysis: The Health Promotion Model and Motivation in Physical Activity.

Background: The health promotion model (HPM) depicts numerous factors impacting health-promoting behavior. Variables of the HPM including experiences, self-efficacy, and the influences affecting health choices portray a comprehensive picture of a person's values and barriers to health behavior change. Perceived harm of inaction is weighed against the perceived benefits of action within the HPM. Physical inactivity is a worldwide concern with deleterious consequences. Strategies are needed to increase physical activity participation to mitigate the impacts. The HPM has not been previously analyzed in the context of adult physical activity. Purpose: Analyze the HPM, apply it to the concept of adult motivation for physical activity, display the utility of theory application in practice, and demonstrate the vital role of nursing in connecting theory to practice. Methods: Theory analysis was conducted using Walker and Avant's method with a focus on motivation for physical activity among adults. Evaluation of the origins, meaning, logical adequacy, usefulness, generalizability, parsimony, and testability of the HPM adds depth to understanding the theory and its application in clinical practice. Results: The HPM is logical, generalizable, and has been broadly applied and tested. Adaptations were made to the HPM to reflect updated knowledge and for application to adult motivation for physical activity. Implications for practice and future research: Thorough evaluation of the HPM facilitates application to clinical practice to impact physical activity health behavior change. Examining motivation for physical activity through the lens of the HPM can guide nursing engagement and interventions to enhance behavior changes.

A Unitary Theory of Healing Through Touch.

Touch has been linked empirically to healing outcomes; therefore, developing theories about the dynamics between touch and healing is important for nursing. A practice-based theory is described within a Unitary Science perspective emerging from the findings of a qualitative descriptive study of the experiences of persons with advanced cancer receiving touch (massage and simple touch) during hospice care. Seventeen participants were interviewed. Through content analysis and retroductive constructivist theory development, healing through touch was described as a dynamic process cocreated by healer and healee, characterized by the simultaneous activities of sensing , reflecting , and connecting . Interpretation of findings from a unitary lens led to an overarching theme of touch as sanctuary and explication of theoretical alignment with the concepts of wholeness, awareness, and presence.

Patient and Provider Perceptions of COVID-19-Driven Telehealth Use From Nurse-Led Care Models in Rural, Frontier, and Urban Colorado Communities.

The purpose of this study was to characterize the patient and provider engagement in the sudden telehealth implementation that occurred with the onset of the COVID-19 pandemic. Patients and providers from 3 nurse-led models of care (federally qualified health centers, nurse midwifery practices, and the Nurse-Family partnership program) in Colorado were surveyed. Data from the Patient Attitude toward Telehealth survey and Provider Perceptions about Telehealth were collected. Patient respondents (n = 308) who resided primarily in rural or frontier communities were female, white, and Hispanic. Patients in urban areas used telehealth more frequently than in rural or frontier areas (P < .001). Rural/Frontier patients had significantly lower attitude scores than urban patients across each of 5 domains assessed. Telehealth modality differed across location (P < .023), with video calls, used more frequently by urban providers, and phone calls used by rural/frontier providers. Our data highlight differences in telehealth access and attitudes across rurality. These findings may contribute to future policy while addressing barriers to telehealth access and delivery.

Mishel's uncertainty in illness theory: Informing nursing diagnoses and care planning.

PURPOSE: Patients with glioblastoma multiforme (GBM) face uncertainty during the illness trajectory that decreases their quality of life. Uncertainty manifests as an altered state of mind in patients with GBM and increases the burden of managing their diagnosis. The uncertainty in illness theory (UIT) can be used to guide nursing practice and create care plans to decrease this uncertainty. DATA SOURCES: The UIT and conceptual model were used to pair diagnoses from NANDA-I Nursing Diagnoses to form care plans for patients with GBM. METHODS: In a stepwise approach, concepts from the UIT were organized and cross-walked into an integrated theory-driven practice framework to enhance care planning. CONCLUSIONS: The UIT helps define and identify circumstances of uncertainty in patients experiencing illness, and Nursing Diagnoses provide engagement and outcomes for those uncertainty-based diagnoses. Some examples of the UIT guiding Nursing Diagnoses includes a patient's cognitive level guiding a Nursing Diagnosis care plan of Risk for Acute Confusion. Social Support can guide the care plan of Risk for Loneliness, and appraisal of uncertainty can guide a care plan for Ineffective Individual Coping. Using the UIT to guide theory-driven practice links interventions and outcomes in patients with GBM. IMPLICATIONS FOR PRACTICE: The UIT can guide NANDA-I Nursing Diagnoses to assist nurses in creating a nursing care plan for nursing engagement to decrease uncertainty and increase the quality of life in patients with GBM. Theory-driven research defines the application of the UIT in GBM and provides foundational knowledge for theory-driven practice to occur.

Nursing, Social Justice, and Health Inequities: A Critical Analysis of the Theory of Emancipatory Nursing Praxis.

Walter's theory of emancipatory nursing praxis (ENP) was created to explore nurses' social justice-related transformational learning process. We analyzed the theory within the context of stigma-related health inequities faced by transgender and gender-diverse (TGD) people. The theory of ENP provides a theoretical framework to incorporate social justice in nursing practice, research, education, and policy. We also determined the theory bridges the gap in understanding the role of nurses in advancing social justice through embodied actions and social activism. The theory of ENP underscores the moral, ethical, and professional obligations for nurses to abolish health inequities for TGD people.

Modeling of an alternative reimbursement method for palliative care.

OBJECTIVES: Patient and Caregiver Support for Serious Illness (PACSSI), a per-member per-month (PMPM) alternative reimbursement structure for palliative care (PC) services, has been described as overly generous by HHS. We developed a modified version, PACSSI-Flexible (PACSSI-F), by modeling reimbursement for PC based on the changes in patient functional status. We estimated reimbursement for the first year that an organization might implement the PACSSI-F for PC services. STUDY DESIGN: Secondary analysis using data from the Statin Discontinuation in Advanced Illness Trial. METHODS: We evaluated the PACSSI vs the PACSSI-F in 3 phases. In the first phase, we calculated variable-appropriate frequencies/relative frequencies or means/SDs for the study population's available demographics and comorbidities, focusing on age, Charlson Comorbidity Index score, race and ethnicity, gender, and continued statin use. Exploratory analyses specific to reimbursement were conducted in a second phase. For each payment structure, we calculated the (1) mean (SD) total reimbursement and (2) number of weeks that a health care system would receive reimbursement, with both weekly and PMPM (4-week) averages. The third phase was designed to quantify any within-person (paired) differences in reimbursement between the original PACSSI and the PACSSI-F. RESULTS: PACSSI-F provides reimbursement for sustainable PC services and was cost-advantageous over PACSSI by $69.92 PMPM for 28.6% of the seriously ill population. CONCLUSIONS: Modeling of the PACSSI-F using secondary data provides a novel example of economic forecasting for alternative reimbursement structures in PC. Alternative reimbursement payment policies are necessary to expand PC for the seriously ill population.

Intrinsic motivation in exercise: A concept analysis.

AIM: To explore the concept of intrinsic motivation in exercise as it pertains to nursing. BACKGROUND: Exercise is an integral part of treating and preventing chronic diseases, and yet the vast majority of adults do not adequately meet endorsed exercise recommendations. Evaluating motivation for exercise assists in the effort to promote sustained exercise participation. Intrinsic motivation speaks to the innate drive for an action or behavior. Intrinsic motivation has previously been evaluated in various disciplines including nursing, education, exercise science, medicine, and psychology. The combination of intrinsic motivation and exercise can be applied in the nursing discipline to evaluate, predict, and impact behavior change. DESIGN: Concept analysis using Walker and Avant (2019) methodology. DATA SOURCE: PubMed, CINAHL, and PsychINFO. Articles from the years 2011 to 2020 were included. REVIEW METHODS: Literature from multiple disciplines was synthesized to explore the concept of intrinsic motivation in the context of exercise. RESULTS: Characteristics of intrinsic motivation, their attributes, antecedents, and consequences were identified. The concept analysis represents a consensus of the identified literature providing a concise description of intrinsic motivation with exercise. Four vital attributes were identified in the literature and became the basis of the concept analysis; self-efficacy, competence, self-determination, and satisfaction. CONCLUSION: This concept analysis provides a foundation from which to create nursing interventions aimed at fostering intrinsic motivation for exercise. Expansion of our knowledge of intrinsic motivation, in the context of exercise, has the potential to enhance approaches used by nurses and nurse providers to affect healthy behavior changes.

Clinical Nurse Specialists in the United States Registered With a National Provider Identifier.

PURPOSE/AIMS: This study illuminates the workforce of the clinical nurse specialist (CNS), using data from the National Provider Identifier (NPI) registry. DESIGN: This is a descriptive exploratory study using CNSs' self-reported data within the NPI registry through December 2019. METHODS: Tabulations for frequencies of available demographics, population foci/specialty, and tests for differences in urban/rural locations were conducted. Clinical nurse specialists practicing as nurse practitioners were also counted and identified. Run charts were used to assess quarterly trends for CNSs obtaining new NPIs. RESULTS: Ten thousand CNSs were registered with an NPI, and 9470 reported 1 population foci/specialty. Furthermore, 1932 CNSs (19.3%) also report working as a nurse practitioner. Only 2 CNS specialties differed by more than 4% between urban and rural areas (respectively): family health (7.7% and 15.5%) and CNSs without a specialty (17.1% and 12.6%). Run charts identified 5 specialties with changing trends in new NPI enumerations (family health, adult-gero, postacute care, pediatrics, and women's health). CONCLUSIONS: Of the estimated 89 122 CNSs in the United States, only 11.2% of the CNS workforce was described and accounted for within the NPI registry. Clinical nurse specialists are encouraged to register for an NPI. Further research is necessary to describe the location and type of work CNSs are performing within the US healthcare system.

A unitary-caring conceptual model for advanced practice nursing in palliative care.

Advanced practice nurses provide expert clinical care for patients and families experiencing chronic and terminal illnesses. However, there is no theoretical framework that guides praxis in palliative care. This article describes a unitary-caring model that transforms national standards of palliative care into a values-based praxis focused on healing and caring.