I-Poems: A Window Into the Personal Experiences of Family Caregivers of People Living With Advanced Cancer.

BACKGROUND: To date, there is little understanding of how caring during advanced cancer can be a transformational experience for personal becoming for family caregivers (FCGs). FCGs experience personal becoming as they create their own meaning of health and illness and choose patterns relating to the self-identity of the past while reaching forward into the unknowns. Gaining greater insight into a potentially positive aspect of cancer caregiving can contribute to family caregiver well-being and quality of life. OBJECTIVE: This paper identifies I-Poems within cancer caregiver narratives and explores them for themes of personal becoming. The narrative environment created space for FCGs to construct and share their voices; at the same time, the analytic method of poetic inquiry provided the voice of the FCGs to be seen, heard, and contextually explored. METHODS: As a secondary analysis, we used five cancer caregiver narrative texts obtained from the primary study to create individual I-Poems. Each of the I-statements within the cancer caregiver narrative texts was lifted and repositioned into a poem format while retaining the chronological order and voice of the participant. We then explored the I-Poems for converging themes of personal becoming as emerged from the primary narrative-thematic analysis. RESULTS: I-Poems were created from each of the five participants caregivers' narratives and then explored for themes of personal becoming. Each of the participant stories is briefly introduced, followed by their I-Poem. We found that the I-Poems converged with emergent themes and provided a first-person representation of their caring journey and transformation of being. DISCUSSION: I-Poems are a postmodern form of poetic inquiry that can be used alongside thematic analysis to explore personal meaning of caring for someone with advanced cancer and how FCGs experience personal transformation of self. While we found I-Poems to be a meaningful and useful form of analysis for some narrative data, we propose an evolved genre of poetic inquiry-We-Poems-to be used in dyadic nursing research and with FCGs who are in partnered relationships.

Best Practices for Telehealth in Nurse-Led Care Settings-A Qualitative Study.

The COVID-19 pandemic in the US prompted a sudden shift to telehealth in nurse-led care sites which provide services to diverse geolocations. Using a lens of intersectionality, this study characterizes provider and patient-perceived best and promising practices emerging from geographical variation. The aim of this study was to identify best practices of implementing telehealth in nurse-led care models in Colorado through patient and provider experiences of the sudden implementation of telehealth that can enhance health equity. In this exploratory/descriptive qualitative study, a purposive sample of 18 providers and 30 patients were interviewed using a guide informed by the RE-AIM implementation and evaluation framework to capture the contextual experiences related to the sudden shift to telehealth. Textual theme analysis and reflexive team strategies guided the interpretation. Four primary themes of perceived best practices were identified: using multiple modalities, tailoring triage and scheduling, cultivating safety through boundaries and expectations, and differentiating established versus new patient relationships. The findings suggest that telehealth is a flexible and powerful tool to enhance the delivery of equitable care through nurse-led care models within diverse communities such as the one represented in this study. Nurse leaders are positioned to participate in innovative research and create policies and protocols to ensure telehealth is a viable resource to deliver equitable, safe, and accessible high-quality healthcare.

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.

Narrative Inquiry as a Caring and Relational Research Approach: Adopting an Evolving Paradigm.

Humans are continuously storying and re-storying themselves through language and socially organizing language into narratives to create meaning through experiences. Storytelling through narrative inquiry can bridge world experiences and co-create new moments in time that honor human patterns as wholeness and illuminate the potential for evolving consciousness. This article aims to introduce narrative inquiry methodology as a caring and relational research approach aligned with the worldview grounding Unitary Caring Science. This article uses nursing as an exemplar to inform other human science disciplines interested in using narrative inquiry in research, while defining essential components of narrative inquiry through the theoretical lens of Unitary Caring Science. By exploring research questions through this renewed understanding of narrative inquiry informed by the ontological and ethical tenets of Unitary Caring Science, healthcare disciplines will be knowledgeable and prepared to facilitate knowledge development to contribute to the sustainment of humanity and healthcare beyond eliminating the cause of illness and into the experience of living well with illness. The co-creative process of narrative inquiry as a caring and healing inquiry can guide collective wisdom, moral force, and emancipatory actions by seeing and valuing human experiences through an evolved holistic and humanizing lens.

Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments.

OBJECTIVES: Safer opioid prescribing patterns, naloxone distribution, and medications for opioid use disorder (M-OUD) are an important part of decreasing opioid-related adverse events. Veterans are more likely to experience these adverse events compared to the general population. Despite treatment guidelines and ED-based opioid safety programs implemented throughout Veterans Affairs (VA) Medical Centers, many Veterans with OUD do not receive these harm reduction interventions. Prior research in other health care settings has identified barriers to M-OUD initiation and naloxone distribution; however, little is known about how this may be similar or different for health care professionals in VA ED and urgent care centers. METHODS: We conducted qualitative interviews with VA health care professionals and staff using a semistructured interview guide. We analyzed the data addressing barriers and facilitators to M-OUD treatment in the ED and naloxone distribution using descriptive matrix analysis, followed by team consensus. RESULTS: We interviewed 19 VA staff in various roles. Respondent concerns and considerations regarding the initiation of M-OUD in the ED included M-OUD initiation falling outside of ED's scope of providing acute treatment, lack of VA-approved M-OUD protocols and follow-up procedures, staffing concerns, and educational gaps. Respondents reported that naloxone was important but lacked clarity on who should prescribe it. Some respondents stated that an automated system to prescribe naloxone would be helpful, and others felt that it would not offer needed support and education to patients. Some respondents reported that naloxone would not address opioid misuse, which other respondents felt was a belief due to stigma around substance use and lack of education about treatment options. CONCLUSIONS: Our VA-based research highlights similarities of barriers and facilitators, seen in other health care settings, when implementing opioid safety initiatives. Education and training, destigmatizing substance use disorder care, and leveraging technology are important facilitators to increasing access to lifesaving therapies for OUD treatment and harm reduction.

Stories of the Heart: Illness Narratives of Veterans Living With Heart Failure.

Background: Illness narratives for veterans living with heart failure (HF) have been largely unexplored, yet HF is a significant and impactful illness affecting the lives of many veterans. Methods: This study used narrative inquiry to explore the domains of psychosocial adjustments using the model of adjustment to illness, including self-schema, world schema, and meaning. Results: Five illness narratives of veterans living with HF were cocreated and explored domains which were found across all the narratives explored in this study. Emergent themes included: uniqueness of the veteran experience and the social, historical, and cultural context of narrator and researcher. Conclusions: Veterans living with HF are a unique population who experience changes in their self-schema, world schema, and meaning through their illness experience. These findings have important implications for interdisciplinary health care research and clinical practice, providing important insight into how people live with chronic illness.

Provider Perceptions of Opioid Safety Measures in VHA Emergency Departments and Urgent Care Centers.

BACKGROUND: A priority for Veterans Health Administration (VHA) leadership is increasing access to lifesaving treatment, particularly naloxone distribution and medication-assisted treatment (MAT) for opioid use disorder (OUD) for veterans. To date, these practices are not widely done in the VHA emergency departments (ED) and urgent care centers (UCC). METHODS: The goal of this research was to understand advanced care provider perceptions of barriers and facilitators to naloxone distribution or MAT initiation in VHA ED/UCCs. We developed and disseminated a survey to VHA ED and UCC advanced care providers, including medical doctors (MD/DO), physician assistants (PAs), and nurse practitioners (NPs). Descriptive statistical analysis was conducted. RESULTS: There was 16.7% response rate (372 out of 2228 providers) from 103 of 132 sites across all VA regions. The top barrier for ED/UCCs providers to both naloxone and MAT initiation was the feeling that it was beyond their scope of practice (35.2% and 53.2%, respectively). Other reported barriers to MAT initiation included unclear follow-up plan and system for referral of care (50.1%) and feeling uncomfortable using MAT medications (28.8%). Top facilitators for prescribing naloxone included pharmacist who could help prescribe/educate the patient on the medication (44.6%) and patient knowledge of medication options to help overdose (31.7%). The top facilitator for MAT initiation from the ED/UCC was additional VA-based same day treatment options (34.9%). CONCLUSIONS: Present findings offer a look into possible challenges to address or opportunities to leverage when considering or developing an ED/UCC-based naloxone distribution or MAT-initiation implementation program in VHA facilities.

Perceived Social Standing in Assisted Living Communities: A Mixed-Methods Study of Social Hierarchies Among Residents.

The purpose of this mixed-methods study was to measure perceived social standing within an assisted living (PSS-AL), and to identify individual determinants and empirical correlates of this construct. The sample consisted of 200 residents of 21 assisted livings (ALs). A self-anchoring ladder measured PSS-AL (M = 6.95, SD = 2.04) and an open-ended follow-up question assessed individual determinants of PSS-AL ratings. In a multiple regression, mental health (ß = .27, p = .001), intimate staff-resident relationships (ß = .22, p = .024), and extraversion (ß = .27, p < .001) were significant predictors of PSS-AL. Qualitative findings revealed that inter-personal factors, prosocial behaviors, and health were key determinants of PSS-AL. Results highlight the social demands of AL and associated implications for residents with varying social abilities, skills, and interests. Findings also suggest that staff-resident relationships may shape and-or reinforce resident social hierarchies. The authors discuss implications for research and practice.

Preparedness and response activities of the US Department of Veterans Affairs (VA) home-based primary care program around the 2017 hurricane season.

BACKGROUND: Large-scale natural disasters disproportionally affect both the medically complex and the older old, groups that are responsible for most medical surge after a disaster. To understand how to ameliorate this surge, we examined the activities of the nine US Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) programs impacted during the 2017 Fall Hurricane Season. METHODS: Convergent mixed methods design, incorporating independently conducted qualitative and quantitative analyses. Phase One: 34 clinical staff were interviewed from the nine VA HBPC programs impacted by Hurricanes Harvey, Irma, and Maria to examine the experiences of their HBPC programs in response to the Hurricanes. Phase Two: Secondary quantitative data analysis used the VA's Corporate Data Warehouse (CDW) to examine the electronic health records of patients for these same nine sites. RESULTS: The emergency management activities of the HBPC programs emerged as two distinct phases: preparedness, and response and recovery. The early implementation of preparedness procedures, and coordinated post-Hurricane patient tracking, limited disruption in care and prevented significant hospitalizations among this population. CONCLUSIONS: Individuals aged 75 or older, who often present with multiple comorbidities and decreased functional status, typically prefer to age in their homes. Additionally, as in-home medical equipment evolves, more medically vulnerable individuals are able to receive care at home. HBPC programs, and similar programs under Medicare, connect the homebound, medically complex, older old to the greater healthcare community. Engaging with these programs both pre- and post-disasters is central to bolstering community resilience for these at-risk populations.

Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis.

Incentive-based pay-for-performance (P4P) models have been introduced during the last 2 decades as a mechanism to improve the delivery of evidence-based care that ensures clinical quality and improves health outcomes. There is mixed evidence that P4P has a positive effect on health outcomes and researchers cite lack of engagement from health care professionals as a limiting factor. This qualitative metasynthesis of existing qualitative research was conducted to integrate health care professionals' perceptions of P4P in clinical practice. Four themes emerged during the research process: positive perceptions of the value of performance measurement and associated financial incentives; negative perceptions of the performance measurement and associated financial incentives; perceptions of how P4P programs influence the quality/appropriateness of care; and perceptions of the influence of P4P program on professional roles and workplace dynamics. Identifying factors that influence health care professionals' perceptions about this type of value-based payment model will guide future research.

Feasibility Study of a Quasi-experimental Regional Opioid Safety Prescribing Program in Veterans Health Administration Emergency Departments.

BACKGROUND: The Veterans Health Administration (VHA) Opioid Safety Initiative (OSI) was implemented in 2013 and was associated with a 25% relative decrease in the dispensing of opioids. Although emergency department (ED) providers play a role in the initiation and continuation of opioids, the incumbent OSI did not target EDs. OBJECTIVE: The goal of this feasibility study was to leverage the existing VHA OSI and test a novel ED-based quality improvement (QI) program to decrease opioid prescribing in multiple ED settings. METHODS: This was a quasi-experimental study of phased-in implementation of a QI ED-based OSI. The general setting for this pilot were four VHA EDs across the Veterans Integrated Services Network (VISN) region 19: Denver, Oklahoma City, Muskogee, and Salt Lake City. We developed and disseminated a dashboard to assess ED-specific prescribing rates and an ED-tailored toolkit to implement the program. Academic detailing pharmacists provided focused audits and feedback with the highest prescribing providers. We measured change in ED-provider prescribing rate of opioids for patients discharged from the ED, by provider and aggregated up to facility level, pre- and postimplementation. RESULTS: Interrupted time-series analysis of provider-level data from the program implementation sites indicated a significant decrease in the trend for proportion of opioid prescriptions relative to the preintervention trend. The results of the analysis suggest that the intervention was associated with accelerating the rate at which ED provider prescribing rates decreased. CONCLUSION: Due to the high volume of patients and the vital role the ED plays in patient treatment and hospital admissions, it is evident that the ED is an important site for QI programs as well as the implementation of opioid safety measures. Given the findings of this pilot, we believe that implementation of a national Veterans Affairs ED OSI implementation is feasible practice.

Hurricanes Harvey, Irma, and Maria: Exploring the Role of Home-Based Care Programs.

OBJECTIVE: The aim of this study is to determine the response of home-based primary care programs to the fall 2017 Atlantic hurricane season. METHODS: This study examines the experiences of 9 Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) programs in their responses to Hurricanes Harvey, Irma, and Maria. Thirty-four phone interviews with HBPC leadership and staff were conducted from April to July 2018. RESULTS: The total census of impacted HBPC programs was 3118. No program reported loss of life due to these hurricanes. Early preparedness was key to an effective program response. Response included prompt tracking of the patients. In the most affected areas, respondents noted limited resources to support basic patient needs. CONCLUSIONS: Medically complex patients served by programs such as the VHA's HBPC program represent a subset of the population, yet they have an outsized impact on health care resources that could be exacerbated by inadequate disaster preparedness. HBPC programs serve a unique role in supporting the "older old." They are tasked with supporting disaster preparedness activities of patients. Understanding what is involved in actualizing their requirements shows communities how to effectively engage with these programs.

Home-Based Primary Care's Role in Supporting the Older Old During Wildfires.

OBJECTIVES: There is limited understanding of how Home-Based Primary Care (HBPC) programs support their medically complex patients in event of a disaster. This study aimed to identify emergency preparedness protocols and procedures undertaken in advance of and due to the 2017 Northern California wildfires by staff of the Veterans Health Administration (VA) HBPC programs. METHODS: This study examines the experiences and responses of two VA HBPC programs to the 2017 Northern California wildfires. Six phone interviews were conducted from July to August 2018. The interview protocol addressed agency preparedness policies and procedures, continuity of care after the wildfires, as well as facilitators and barriers to disaster response. RESULTS: The total patient census of participating HBPC programs was 300. Neither HBPC program reported a loss of life due to the wildfires. Early patient preparedness, effective leadership support, and strength of program operating procedures emerged as key factors to effective response. CONCLUSIONS: Demand for home health care, like VA's HBPC program, is projected to grow as the number of older adults and longevity increases. Emergency management efforts must likewise evolve to address the unique needs of these vulnerable patients in disasters. Understanding the program activities conducted by the VA HBPC programs in response to the 2017 Northern California wildfires can help improve the understanding of how VA and non-VA home-based care programs can be best integrated into resilience planning of local communities.

Improving Early Palliative Care with a Scalable, Stepped Peer Navigator and Social Work Intervention: A Single-Arm Clinical Trial.

BACKGROUND: Patients with cancer could benefit from early primary (i.e., basic) palliative care. Scalable models of care delivery are needed. OBJECTIVE: Examine the feasibility of a stepped peer navigator and social work intervention developed to improve palliative care outcomes. DESIGN: Single-arm prospective clinical trial. The peer navigator educated patients to advocate for pain and symptom management with their healthcare providers, motivated patients to pursue advance care planning, and discussed the role of hospice. The social worker saw patients with persistent psychosocial distress. SETTING/SUBJECTS: Patients with advanced cancer at a VA Medical Center not currently in palliative care or hospice whose oncologist would not be surprised if the patient died in the subsequent year. MEASUREMENTS: Participation and retention rates, patient-reported symptoms and quality of life, advance directive documentation, patient satisfaction survey, and semistructured interviews. RESULTS: The participation rate was 38% (17/45), and 35% (7/17) completed final survey measures. Patients had stage IV (81%) and primarily genitourinary (47%) and lung (24%) malignancies. Median Eastern Cooperative Oncology Group performance status was 0. Patient-reported surveys indicated low distress (mean scores: Functional Assessment of Cancer Therapy-General, 75.3 [standard deviation {SD} 17.6]; Edmonton Symptom Assessment Scale symptom scores ranged from 1.6 to 3.8; Patient Health Questionnaire-9, 5.7 [SD 5.2]; and Generalized Anxiety Disorder-7, 2.8 [SD 4.1]). Of those who had not completed advance directives at baseline (n = 11, 65%), five completed them by the end of study (5/11, 45%). Patients who completed satisfaction surveys (n = 7) and interviews (n = 4) provided mixed reviews of the intervention. CONCLUSIONS: At a single site, a stepped peer navigator and social work palliative care study had several challenges to feasibility, including low patient-reported distress and loss to follow-up.

Development and Feasibility of a Structured Goals of Care Communication Guide.

BACKGROUND: Discussing goals of care and advance care planning is beneficial, yet how to best integrate goals of care communication into clinical care remains unclear. OBJECTIVE: To develop and determine the feasibility of a structured goals of care communication guide for nurses and social workers. DESIGN/SETTING/SUBJECTS: Developmental study with providers in an academic and Veterans Affairs (VA) health system (n = 42) and subsequent pilot testing with patients with chronic obstructive pulmonary disease or heart failure (n = 15) and informal caregivers (n = 4) in a VA health system. During pilot testing, the communication guide was administered, followed by semistructured, open-ended questions about the content and process of communication. Changes to the guide were made iteratively, and subsequent piloting occurred until no additional changes emerged. MEASUREMENTS: Provider and patient feedback to the communication guide. RESULTS: Iterative input resulted in the goals of care communication guide. The guide included questions to elicit patient understanding of and attitudes toward the future of illness, clarify values and goals, identify end-of-life preferences, and agree on a follow-up plan. Revisions to guide content and phrasing continued during development and pilot testing. In pilot testing, patients validated the importance of the topic; none said the goals of care discussion should not be conducted. Patients and informal caregivers liked the final guide length (∼30 minutes), felt it flowed well, and was clear. CONCLUSIONS: In this developmental and pilot study, a structured goals of care communication guide was iteratively designed, implemented by nurses and social workers, and was feasible based on administration time and acceptability by patients and providers.

Can we engage caregiver spouses of patients with heart failure with a low-intensity, symptom-guided intervention?

OBJECTIVE: Evaluate a pilot intervention to engage caregivers in management of heart failure (HF) patient symptoms. BACKGROUND: HF impairs quality of life; caregivers provide an important role in HF management. METHODS: We developed modules to help patients report and caregivers alleviate symptoms of depression, pain, dyspnea, and fatigue. Semi-structured interviews followed by a mixed inductive and deductive, team-based analysis were used to evaluate acceptability and feasibility in patients with HF and their caregivers. RESULTS: Participants (n = 22) expressed significant interest but few used the modules in follow-up. We identified three barriers to acceptability and feasibility: the quality of dyadic relationship, the timing and structure of the intervention, and the patient's perceived control over their illness. CONCLUSIONS: Future interventions should evaluate dyadic relationship dynamics, match the timing and content of the intervention to the patient population, and enroll patients with perceived control over their illness to maximize intervention acceptability and feasibility.